Shop Alto Essentials to add pharmacy products to any delivery!

Your partner in navigating the ins and outs of prescriptions — at no extra cost.

Alto Pharmacy Technician

Alto Pharmacist

It’s official: Alto Pharmacy is a great place to work! We’re honored to join the community of Great Place to Work-Certified™ companies based on team member feedback and a rigorous assessment of our company’s culture and benefits.

Join us in delivering our industry-leading pharmacy care to millions of people across the country. As a member of the team, you’ll play an integral role in improving our customers’ quality of life and redefining what’s possible in pharmacy. 

Be Part of a Great Place to Work — Join Our Team

Hear first-hand from members of the Alto technology teams.

Read the latest Alto blog posts covering healthcare, family health, managing diseases, and other Alto highlights.

Blog | Alto Pharmacy

The term “donut hole” refers to a gap in Medicare Part D prescription medication coverage. Once this coverage gap starts, you will likely pay more out of pocket for your medications. Here’s what to know about the Medicare donut hole, including how it may affect the cost of your prescription medications this year.

The Medicare Donut Hole, Explained

Medicare is a federally-run health insurance program for people age 65+ and people with disabilities, regardless of income. It is different from Medicaid, which is a state and federal program that provides health coverage if you have a very low income.

Part A: coverage for inpatient hospital visits and skilled nursing facility services

Part B: coverage for physician and outpatient hospital services and durable medical equipment (DME) costs, including insulin pumps, blood sugar test stips, some continuous glucose monitors (CGMs), nebulizers, and oxygen equipment

Part C, also known as Medicare Advantage (MA) plans: offered by private insurance companies to provide the same benefits as Medicare Parts A and B; many also offer prescription coverage similar to Part D

Part D: coverage for prescription medications that are commonly dispensed from the pharmacy including respiratory medications and injectable insulin; may cover insulin patch pumps; you can change Part D plans each year

Part D plans have an annual coverage gap known as the donut hole. Once this begins, you will pay more for your medications until you reach the yearly limit on out-of-pocket costs.

The donut hole begins when your Medicare plan has paid a certain amount toward your prescription medications in a given year. This is sometimes referred to as the initial coverage limit. In 2022, the initial limit for prescription drug coverage on Medicare Part D plans is $4,430/year, an increase from $4,130 in 2021. 

Once in the donut hole, you become responsible for no more than 25% of your medication costs until you hit a certain out-of-pocket threshold and can exit the donut hole. For example, if a medication’s total cost is $100 and you pay a $20 copay during the initial coverage period, you will be responsible for paying $25 — 25% of $100 — while in the donut hole.

The out-of-pocket threshold is the amount of money you have to spend out of pocket before you are allowed to leave the donut hole. In 2022, the out-of-pocket threshold for Part D plans is $7,050, an increase from $6,550 in 2021.

The following count toward your total out-of-pocket costs while in the donut hole:

Out-of-pocket expenses for generic and brand-name medications

After you’ve reached the out-of-pocket threshold, you receive “catastrophic coverage.” During this time, your share of medication costs will drop significantly to either 5% of a medication’s cost or a small copay — whichever is higher.

The minimum copay for a one-month supply of generic medication for Medicare Part D plans in 2022 is $3.95, and the minimum copay for a one-month supply of brand-name medication is $9.85.

Medicare Extra Help offers financial assistance with monthly premiums, annual deductibles, and copay costs related to prescription medications. Eligibility is income-based. Those who receive Medicare Extra Help will not enter the donut hole.

To qualify for the program in 2022, annual income is limited to $20,385 for an individual or $27,465 for a married couple living together.

For more information on Medicare and the donut hole, we suggest exploring the following resources.

www.medicare.gov - includes live chat and 1-800-MEDICARE (1-800-633-4227)

The Medicare and You Handbook - includes key deadlines for enrollment and details on coordinating third party coverage from former employers, the military, and Veterans Affairs.

The Medicare Plan Finder - a trusted source for comparing Medicare coverage options.

Your choice of pharmacy can significantly impact the cost of your medications. At Alto, we prioritize your financial wellness alongside your physical health. Here are some ways we go above and beyond to ensure that you’re receiving your medications at the lowest price possible.

We research all your pricing options once we receive a prescription. If it is cheaper to pay cash for your medications, separate from insurance benefits, we’ll let you know so that you can make an informed choice.

We automatically search for potential sources of savings like manufacturer coupons, patient assistance programs, and copay cards and apply them when applicable. If we find any options that require you to apply directly with the program or manufacturer, we’ll let you know.

We continue searching for less expensive medication options even after we’ve researched savings opportunities, coordinating with your doctor to evaluate these options.

To get started or learn more about Alto, call 1-800-874-5881 or reach out through in-app messaging.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.

Traveling with any type of medication requires advanced planning. For those with diabetes, it’s even more imperative to prepare, as there are additional factors to consider like insulin temperature control and TSA screening of diabetes supplies and equipment. Use the suggestions below to make sure you have everything you need to manage your diabetes while away from home.
Consulting your doctor

Traveling With Diabetes: How to Prepare

Traveling with any type of medication requires advanced planning. For those with diabetes, it’s even more imperative to prepare, as there are additional factors to consider like insulin temperature control and TSA screening of diabetes supplies and equipment. Use the suggestions below to make sure you have everything you need to manage your diabetes while away from home.

Schedule an appointment with your diabetes care provider before your trip to make a plan for diabetes management during your travels. Be sure to cover the following:

How will planned activities impact your care needs?

What is the recommended frequency of blood sugar monitoring?

How might changing time zones impact the timing of your insulin dosage? 

Are there any recommended vaccines for your trip?

Keep in mind that eating and physical activity levels can shift during travel — sometimes unexpectedly — so it’s important to prepare for changes in your blood glucose levels.

Travel doesn’t always go as planned, so it’s important to have extra diabetes supplies and medication on hand. A good rule of thumb is to pack twice as many supplies as you think you’ll need and to bring additional paper prescriptions for insulin or other diabetes medications.

If traveling internationally, be mindful that prescription laws vary by country. It’s a good idea to contact the U.S. embassy of the country you’re visiting for more details. Some countries may only allow a 30-day supply for certain medications and/or require you to carry an official prescription or additional information from your doctor with you.

In addition, keep your health insurance card on you throughout the duration of your travels, and review your policy for travel-related details, including whether your destination is included in your provider network.

Here’s a list of potential diabetes medications and supplies to pack. Depending on your diabetes treatment plan, some may not be relevant for you. If you’re unsure what to bring — or how much to bring — ask your diabetes care team.

Enough insulin and syringes for your trip, plus extra

Enough oral medications for your trip, plus extra

Sources of glucose to restore blood glucose levels in the event of low blood sugar, or hypoglycemia, such as over-the-counter glucose tablets (Lift Glucose Chews, TRUEplus® Glucose Tablets, ReliOn™ Glucose Tablets), over-the-counter glucose gel (Dex4® Glucose Gel, Glutose™ 15/Glutose™ 45, Insta-Glucose®), or carbohydrate-rich snacks like dried fruits, trail mix, honey, or granola bars

For a detailed list of diabetes management essentials, read How to Prepare a Diabetes Emergency Kit.

If you are traveling on a longer flight with meal service, contact your airline and ask if it’s possible to request a meal tailored to your dietary needs, with low sugar, fat, and cholesterol values. Be sure to have other food on hand in case there are any issues with your meal.

Make sure others know that you have diabetes. If traveling with others, inform them of what to do in the event of a hypoglycemia emergency. If traveling alone, have a medical ID bracelet or another form of identification that communicates your diabetes diagnosis. You should also carry a list of your current medications and doses and provider contact information.

It’s always best to pack important medications in your carry-on rather than in a checked bag. Since you’ll be bringing additional supplies and medications as a back-up, make sure at least half of them are in your carry-on.

While the U.S. Transportation Security Administration (TSA)’s current limit on liquids, gels, and creams in a carry-on bag is 3.4 ounces (100 milliliters), there are exceptions for diabetes supplies and medications. Give yourself extra time to allow for additional screening of these items. If you use a diabetes device attached to your body, such as an insulin pump or glucose monitor, it will likely require additional screening as well.

Here are some tips that may help you get through security as efficiently as possible.

Inform the TSA officer that you are carrying more than 3.4 ounces of liquid medication before your screening process begins, if applicable.

Consider printing a TSA notification card describing your condition to hand to the TSA officer.

Bring a copy of your prescription(s) with you.

Keep all medications and supplies in their original packaging.

Put your medications and supplies in a separate, clear bag, as they will need to be separated from the rest of your belongings.

If you take insulin, make sure you have what you need to keep it refrigerated. Keep in mind that insulin should not be held at extreme temperatures and storing it in an ice pack can make it unusable. Many people with diabetes use insulated medication bags to hold insulin at an appropriate temperature when traveling.

Read Taking Care of Your Insulin to learn more about safe insulin storage.

It’s important to stay proactive about your diabetes management. There may be times when you have to check your blood sugar even more frequently, for example, if you are more active than usual, and adjust your meal plans accordingly. Keep in mind that hot weather can also impact your body’s insulin use and your blood sugar levels.

Continue to hold insulin at an appropriate temperature during your travels and avoid leaving it in a hot car — including the glove compartment or trunk — or anywhere with direct sunlight. The same applies to other diabetes supplies like your blood sugar monitor and insulin pump.

If you are going on a longer trip, with a full itinerary, try to take it easy for the first few days as your body adjusts. Remember to bring snacks with you on busy days with long activities.

A diabetes pharmacy partner you can rely on

At Alto, we make it as easy as possible to manage your diabetes when traveling. We offer free, same-day delivery of medication and supplies right to your doorstep, and our dedicated diabetes team is here to answer any questions you may have before your trip.

Reach out any time via in-app secure messaging or phone at 1-800-874-5881.

All third party trademarks (including logos and icons) referenced by Alto Pharmacy remain the property of their respective owners. Unless specifically identified as such, Alto’s use of third party trademarks does not indicate any relationship, sponsorship or endorsement between Alto and the owners of these trademarks.

Alto’s launch in the Long Island market extends our industry-leading patient care model to even more of the New York metro area.

Hello, Long Island!

Alto’s launch in Long Island, New York, extends our industry-leading patient care model to even more New York-area residents.

With the addition of our latest pharmacy location in Plainview, Long Island, even more residents of the greater New York City metro area can now choose Alto’s same-day doorstep delivery for all of their pharmacy needs. Alto Long Island opens its doors today, Tuesday, April 5, 2022.

At Alto, we believe it’s our job to ensure you have your medications at the best price, on time and with the support you need. We bring the pharmacy to you - no more waiting in line, making an extra trip, or finding out your prescription isn’t ready to be picked up after you’ve already arrived. Our free doorstep delivery means your medications come directly to you on the day and time you select, and most medications are available the same-day. Stay up to date on your courier’s progress with text alerts and in our mobile app. 

Starting a new medication or doing an injection for the first time? Message a pharmacist with your questions, even in the evenings and on weekends. And we’re a full service pharmacy - we stock all major brand, generic, over-the-counter and specialty medications, meaning your entire family’s pharmacy needs can be managed in the Alto app and coordinated into one delivery.

Courier delivery windows
Monday - Friday: 

12:30 – 3:30 pm ET (1:30 – 4:30 pm ET for outlying areas)*

6:00 – 9:00 pm ET (7:00 – 10:00 pm ET for outlying areas)

2:00 –5:00 pm ET (3:00 – 6:00 pm ET for outlying areas)

Need to pick up? Our new Long Island pharmacy is located at 100 Manetto Hill Road, Suite 104, in Plainview.

Monday - Friday: 9:00 am – 7:00 pm ET
Saturday - Sunday: 8:00 am – 4:30 pm ET

New York residents interested in using Alto’s services for their medication needs can ask their doctor’s office to send all prescriptions to Alto Pharmacy (via ePrescribe or phone). Have existing prescriptions at another pharmacy? Start a transfer online or give us a call at 1 (800) 874-5881, and we’ll handle the switch. 

General customer support hours are Monday - Friday 9 am - 12 midnight ET and Saturday - Sunday 10 am - 9 pm ET. Patients can reach out to Alto via phone at 1 (800) 874-5881 or app.

*Weekday afternoon delivery is only available to residents of New York City's five boroughs at this time.

Founded in 2015, Alto is a patient-centric digital pharmacy based committed to the health and wellbeing of you and your family. We provide free same-day delivery to your door seven days a week for prescriptions, but, more importantly, offer cost transparency, personalized in-app and phone support, and real-time coordination with doctors and insurance companies to get you the care that you need. Alto is headquartered in San Francisco with offices in Denver and Dallas, and currently delivers across the greater Bay Area, Los Angeles, Orange County, San Diego, Seattle, Denver, Las Vegas, New York City, Houston, Dallas and Austin.

Alto’s mission is to improve the quality of life for all who need medicine, building a pharmacy experience that serves people of all backgrounds. As we work toward a more inclusive and accessible healthcare system, we recognize the importance of diversity among physicians, pharmacists, nurses, and other public health figures. In honor of Black History Month, take a moment to learn about five influential Black healthcare leaders past and present — those who paved the way and those who continue to break barriers today

Five Black Healthcare Leaders to Celebrate

Alto’s mission is to improve the quality of life for all who need medicine, building a pharmacy experience that serves people of all backgrounds. As we work toward a more inclusive and accessible healthcare system, we recognize the importance of diversity among physicians, pharmacists, nurses, and other public health figures. In honor of Black History Month, take a moment to learn about five influential Black healthcare leaders past and present — those who paved the way and those who continue to break barriers today. (For additional inspiration, revisit the first post in this series.)

Dr. M. Jocelyn Elders: the first Black U.S. surgeon general

As a Black woman born to farmers in a rural, poverty-stricken area of Arkansas, M. Jocelyn Elders encountered numerous obstacles on her path to becoming the first Black U.S. Surgeon General in 1993. At 16, she met a doctor for the first time, but she didn't consider a profession in healthcare until she connected with Edith Irby Jones, the first Black person to attend the University of Arkansas Medical School, during college.

Throughout her career, Dr. Elders balanced clinical practice and research, increasing the public’s awareness of adolescent health issues. In 1987, Bill Clinton, then the governor of Arkansas, appointed Dr. Elders as head of the state’s Department of Health. The Arkansas state legislature mandated sexual education and substance misuse prevention programs in the K-12 curriculum in 1989 in large part because of Dr. Elders’ advocacy. During her tenure as Surgeon General, Dr. Elders continued to champion progressive policies, advocating for better sexual education programs, distribution of condoms in schools, and abortion rights. She remains active in the field of public health as a professor emeritus at the University of Arkansas School of Medicine.

Bernard J. Tyson: former CEO of Kaiser Permanente

As chairman and CEO of Kaiser Permanente, Bernard Tyson transformed the company’s services to account for social determinants of health like food access and affordable housing as well as the importance of mental health and wellness. He was also instrumental in the development of the Kaiser Permanente School of Medicine, which trains physicians to be not only clinicians, but patient advocates and innovators, too. By shining a spotlight on how social determinants of health contribute to disparities in health outcomes, Tyson leaves behind a legacy that reaches far beyond Kaiser’s services.

Nadine Burke Harris: first surgeon general of California

A physician, researcher, advocate, and California’s first surgeon general, Dr. Nadine Burke Harris has transformed how our society responds to childhood trauma. While running a health clinic in an underserved San Francisco neighborhood, she observed that preventative health practices and quality treatment didn’t resolve her patients’ risk for poor health outcomes. Drawing upon research from the CDC and Kaiser Permanente on adverse childhood experiences (ACEs), which linked early adversity to higher rates of chronic illness later in life, Dr. Burke Harris studied her own patients and found that more than 67% had experienced at least one ACE. She has helped increase public awareness of ACEs and toxic stress, advocating for universal screening of children and adolescents for signs of trauma. Her 2014 TED Talk, “How Childhood Trauma Affects Health Across the Lifetime,” has been viewed more than 7.5 million times, and she published The Deepest Well: Healing the Long-Term Effects of Childhood Adversity in 2018.

Dr. Patrice Harris: first Black female president of the American Medical Association

Despite not knowing any doctors while growing up in West Virginia, Dr. Patrice Harris’ passion for medicine started early. The board-certified psychiatrist initially planned to pursue pediatrics but shifted her focus after discovering an interest in psychiatry during medical school. Her focus on child psychiatry allows her to merge her passion for children with her expertise in mental health. Throughout her career, Dr. Harris has focused on the role of implicit bias within the medical profession and how unconscious biases among healthcare workers influence health disparities.

Dr. Harris’ involvement in the professional healthcare community spans many leadership positions at state and national organizations. She became the first Black woman elected as president of the American Medical Association in 2020. During her tenure, she focused on a variety of health issues, from opioid addiction to COVID-19. She previously chaired the AMA’s Opioid Task Force, providing evidence-based recommendations to clinicians with the goal of ending the opioid epidemic.

Betty Smith Williams: first Black graduate of the Frances Payne Bolton School of Nursing

Betty Smith Williams was the first Black student to earn a nursing degree from Cleveland’s Frances Payne Bolton School of Nursing, in 1954, and the first Black individual to teach at a higher education institution in the state of California, but her individual accomplishments are only a part of her legacy. Williams has helped ensure that today’s aspiring Black healthcare professionals have the opportunities and support to break down barriers of their own. She was instrumental in developing the National Black Nurses Association and the National Coalition of Ethnic Minority Nurse Associations, Inc. — initiatives that have elevated the voices of Black nurses within the profession. In uniting Black nurses, Williams hoped to create better health outcomes among the Black community. In her own words: "We had no voice, but we understood our culture and our unique needs better than anyone else.”

Join us in delivering our industry-leading pharmacy care to millions of people across the country. As a member of the team, you’ll play an integral role in improving our customers’ quality of life and redefining what’s possible in pharmacy. View our current openings.

With more engineers contributing to Alto’s codebase than ever before, we needed to establish better boundaries: which team owns what? Here’s how we developed a tagging-based solution to code ownership and drove and measured adoption.

How We Established Better Boundaries and Clearer Code Ownership at Alto

Some problems are nice to have. Over the course of 2020 the engineering team at Alto saw explosive growth, expanding from about fifteen to more than seventy individual contributors. Growth at this pace required us to rethink our team structures and priorities more than once. This growth felt amazing: the new capacity enabled us to make progress on our backlogs like never before.

But still, there were challenges. We saw a steady rise in merge conflicts as more people contributed to the same code base. Build times increased as more and more code was contributed. A big influx of new perspectives and talent also meant new gaps in historical context and responsibility. New teams took big bites out of their new priorities — great! But what about the old ones? Who was going to fix that bug? Who needs to review this PR? Who is accountable for this performance problem?

Who, in short, owned what? By the end of 2020, it was clear to us that a good, practical, working answer to this question would be the critical first step to continuing smooth, rapid, distributed iteration on our product.

Up to this point, the large majority of product development at Alto had happened in the context of a Ruby on Rails monolith, which — over a half decade of intense development — had grown pretty large. We’d stuck more or less to the default Rails convention of organizing code by function rather than feature, which meant that our code was distributed across a few mostly flat and very broad subdirectories such as '/models' and '/controllers', making it difficult to learn much about the structure and ownership of our business domains by merely looking at how the code was laid out. We knew that this was not going to work for us over the long term.

Our long term vision started to coalesce around a notion of “better boundaries.” First, we would modularize the monolith along the lines suggested by Shopify’s packwerk utility. Then, we would carve some of those modules out into separate engines that could be built and tested separately. Finally, we’d deploy and operate some of those engines independently as their own services. Clear ownership was fundamental to this plan: on either side of an effective boundary, you need to know not just what it is but also who owns it. We lacked that clarity.

The RFC (Request for Comments) we ultimately adopted opened with four questions:

How might we produce a domain model and do something useful at the same time?

How will we avoid imposing (the wrong) prescriptive model from the top down?

How will we keep it up to date and accurate?

We considered jumping straight into moving files around into a more modular structure. Ultimately we decided against this approach as a first step for a number of reasons. The benefit of moving files around is mostly abstract — it’s not immediately clear what to do with a better module structure. It’s relatively expensive to move files around in a Rails app — doing so typically requires you to rename the contents (and update all its callers), which amounts to a lot of busy work, and it’s extra expensive to be wrong. And the in-between state is rough: which example should I follow in deciding where to put my new file? First you are obligated to create a map of the future state, and then to keep that map in sync with reality as you go.

Instead, we opted for a lightweight solution that would allow us to map our domains and their owners in the code itself — helping to ensure it’s up to date and accurate — without having to restructure it at the same time. We’d do this by tagging code in code comments, and then building tools to leverage these tags in various ways to increase visibility and enforce ownership. This has the nice effect of producing a new domain map incrementally from the bottom up, rather than prescriptively from the top down.

We called this the '@owners' tag, and it looks like this:

# @owners { team: platform, domain: orders }
class Wunderbar::OrdersController < Wunderbar::WunderbarController
  def show
		...
  end

  # @owners { team: inventory }
  def out_of_stock
    ...
  end
end

We based our tooling around extending the YARD documentation tool to recognize this as a custom tag. You can teach YARD to recognize a custom tag by passing a command line option like '--tag owners:"Owners"', which by default will cause the tag value to appear in generated documentation under the header “Owners”. The Ruby API for declaring a tag programmatically is shown in the snippet below as well.

We wanted the tag to be interpreted hierarchically to handle cases where ownership has diverged within the same class or module, such that we might want to tag one or two methods differently from the rest, as well as to ease the burden when all of the classes / modules / methods under a namespace belong to the same team and domain, since you can just tag the shared parent. We set an initial goal around getting 100% of our methods covered by at least a “team” value, at which point we would require all code to be covered in our build process.

To get a basic feel for how to work with these tags, make sure the 'yard' gem is available, tag a couple of your files, and then try running the code below in your project. It will print out the tag associated with each tagged code block.

require 'yard'
# Define the custom tag.
YARD::Tags::Library.define_tag('Owners', :owners)

# Parse your codebase. You might want to pass a more specific path here.
YARD.parse('.')

# Load all the method, class and module code blocks into memory
code_blocks = YARD::Registry.all(:method, :class, :module)

# Print the tag associated with each tagged block.
code_blocks.each do |code_block|
  tag = code_block.tag('owners')
  # automatically tag nested classes, modules and methods.
  while tag.nil? && code_block.namespace != nil && [:class, :module].include?(code_block.namespace.type)
    code_block = code_block.namespace
    tag = code_block.tag('owners')
  end
  print "Code Block: #{code_block}, tag: #{tag.text}, line: #{tag.line}" if tag
end

We ultimately developed a handful of CLI tools based on this technique that allow us to produce reports measuring the percentage of code covered by team and domain at different levels, among other things:

bin/yardowners --help
Usage: bin/yardowners [options]
        --methods                    view by methods
        --files                      view by files
        --teams                      teams report
        --domains                    domains repot
        --team=TEAM                  filter by team
        --domain=DOMAIN              filter by domain
        --codeowners                 update codeowners
        --lint                       lint owners tags
        --require-domains            lint for presence of domain in  
owners tags
    -h, --help                       display this help and exit

We use this CLI to add checks to our CI process around coverage / correctness, as well as to report progress toward our goals of 100% coverage.

To get the tagging process started across the organization, we dumped all of our class and module names (thanks again, YARD!) into a big spreadsheet, and then asked each team to get together and spend a bit of time putting their names next to the ones they owned. We adopted the attitude that it was better to have the wrong value than no value, since it would be easy to adjust later.

We covered a good 80% of the code using this spreadsheet by the time each team had taken an initial pass. From there, we filled the blanks in with “TODO”, and then wrote a little script to automatically insert the tags into the code (again based on the YARD metadata, which conveniently gives you the line numbers for the top of each class / module declaration).

At that point, we enabled a linter requiring 100% team owner coverage on all new PRs. We set a new goal to eliminate TODOs, and chipped away at it over the course of a month or so. We then repeated this process for the “domain” values, driving that to 100% as well. We found that the spreadsheet-based divide-and-conquer approach allowed us to cover a lot of ground very quickly.

Once we were able to parse our '@owners' tags, the first and most important thing we did with them was to automatically generate our CODEOWNERS file. We enforce that each tagged team maps to a team name in github and check that CODEOWNERS is up to date during the build process. This new process introduced some friction, as teams started getting tagged every time a file they were tagged on changed. This turned out to be great, because it sparked a number of very productive negotiations around ownership and scope that got hashed out in code review. We keep our CODEOWNERS file synced with Sentry, too, so that exceptions raised by files you tagged as yours get assigned to your team automatically. We also track and report on the performance of individual endpoints by team according to how they are tagged.

The new owners tag hasn’t fixed all our problems by any means, but it has proved fundamental to our ability to operate as a growing set of increasingly independent teams with well specified responsibilities. In subsequent posts, we’ll talk more about how we’re using our new domain map and a suite of other cool tools to build better boundaries within and ultimately escape from our monolith.

Interested in learning more about engineering at Alto? Follow us on LinkedIn.

An HIV diagnosis is the beginning of a lifelong health journey, and it’s understandable to experience many different emotions as you process this information. Remember that HIV is manageable, like many other chronic health conditions, and with treatment, you can live a full and active life. Though it may feel overwhelming to take action right after a diagnosis, getting started on HIV medication as soon as possible is critical to protecting your health and others. Here are the most important steps to take as you move forward.

Next Steps After an HIV Diagnosis

More than half of all individuals living with HIV in the U.S. are not at risk of transmitting the virus to others. This is a testament to the effectiveness of antiretroviral therapy (ART), the frontline treatment for HIV.

ART is a combination of medications that stops the progression of HIV and reduces your viral load — the amount of HIV in your blood — to a very low level. When taken as prescribed every day, these medications can help you maintain an undetectable viral load, which preserves the strength of your immune system and protects the health of your sexual partners. Many people living with HIV are able to achieve an undetectable viral load within six months of starting ART.

Finding a healthcare provider for HIV treatment

There are several ways to find a healthcare provider for HIV treatment. If you already have a primary care provider, they may have the experience and knowledge to treat your HIV. If not, they will likely be able to give you a referral. Similarly, if you were tested for HIV at a clinic, ask if they offer ongoing HIV treatment or can refer you elsewhere. You can also use HIV.gov’s search tool to find HIV treatment services near you.

There’s a lot of information to take in when first starting HIV treatment. Having open conversations with your doctor about your questions and concerns can help you feel empowered about your health. It may help you to prepare a list of questions before your first appointment. Here are some suggestions to use as a starting point.

How will you decide which ART medications are best for me?

How will I know if the medication is working?

What is the frequency of follow-up testing and blood work?

Are there things I cannot do because I am HIV positive?

How does HIV affect my reproductive health? (if relevant)

Learning more about HIV and preventing transmission

Living with HIV often feels more manageable when you’re equipped with facts and confident in your understanding of the condition. In addition to asking questions during doctor’s appointments, explore trusted resources like the CDC's website and HIV.gov to familiarize yourself with the basics of HIV treatment and prevention.

Many individuals are concerned about the risk of potentially transmitting HIV to a partner. There are things you can do to prevent transmission and keep your sexual partners safe. Being consistent with HIV treatment in the long term can virtually eliminate your risk of transmitting HIV to others so long as you maintain an undetectable viral load. This is why one of the most important things you can do, for both your health and others, is to start ART as soon as possible. In addition, your partner or partners may want to speak with their doctors about PrEP, an HIV prevention medication that can lower risk of sexual transmission of HIV by 99% when taken daily. Many individuals who have an HIV-positive partner take PrEP for HIV prevention.

You may be wondering who to tell about your HIV diagnosis. While sharing your HIV status with sexual partners may feel uncomfortable or scary, it will allow them to take steps to protect their health. Some states have laws that require you to share your HIV status with sexual partners. These laws also account for the risk of HIV transmission through intravenous drug use and require you to disclose your HIV status with anyone you share drugs or needles with, if relevant.

Sharing your HIV status with all of your healthcare providers is also important. It will allow them to provide individualized health recommendations, coordinate with the rest of your care team, and take appropriate precautions during blood draws and other procedures.

Many individuals living with HIV find it helpful to share their status with close friends and family as they process their diagnosis. Each person’s experience of HIV is unique, and deciding if and when to tell loved ones about your status is a personal choice. It can be helpful to hear how others decided to share their HIV status. The CDC has a collection of stories about life with HIV, and Positive Spin is another resource highlighting personal experiences of HIV.

The stress of living with any chronic condition can impact your mental and emotional well-being, and those with HIV have a higher chance of developing mental health disorders such as depression.

It’s important to take your mental health as seriously as your physical health and seek any support you need. Use your HIV treatment provider as a resource. They may be able to recommend treatment or prescribe medication, if needed, or refer you to a psychiatrist or psychologist for additional support.

Navigate HIV treatment with Alto by your side

Our pharmacists have deep expertise in HIV treatment and prevention and can help you get started with antiretroviral therapy. We will coordinate with your doctor and your insurance provider, if applicable, to ensure that you’re receiving the best option for your needs at the best price. To learn more, reach out any time through in-app secure messaging or by phone at 1-800-874-5881.

While fertility preservation treatments like egg freezing and IVF are significant investments of time and resources, there are many ways to lower or manage the costs of treatment. As you prepare for the financial aspects of treatment, be sure to explore all of your options for financial assistance and savings, including patient assistance programs from fertility medication manufacturers.

A Guide to Ferring Pharmaceuticals’ Fertility Medication Savings Programs

If Alto is your fertility pharmacy, your fertility medication protocol may include medications manufactured by Ferring Pharmaceuticals, which has several financial assistance programs that offset the cost of fertility medications. Here’s more on eligibility for these programs and how to apply.

The OneHeart program provides a $200 rebate for out-of-pocket costs for select Ferring fertility medications. Eligibility is for those with no insurance coverage or commercial health insurance plans. In addition, you must have started your ovarian stimulation cycle between June 1, 2020 and June 30, 2022, with all medications purchased by June 30, 2022.

Learn more about program terms and conditions and the application process.

The HeartFelt program helps individuals whose cycles were canceled due to COVID-19 or a natural disaster resume fertility treatment. It offers medication replacement for up to 15 vials of Menopur® and up to five syringes of Fyremadel™ (ganirelix acetate) depending on the amount of medication used in the canceled cycle. Eligibility is for those with no insurance coverage or commercial insurance coverage.

To learn more about program terms and conditions and the application process, download the HeartFelt brochure on Ferring’s patient resources page.

The HeartTomorrow program provides Menopur® at $68 per vial for those undergoing an elective egg freezing cycle. To be eligible, you must be paying cash for your fertility medications and purchase a minimum of 20 vials in your first fill.

The Heart for Heroes program provides IVF medications at no cost to eligible military veterans who have experienced infertility due to a service-related injury or who do not have insurance coverage for fertility medications. To learn more about terms and conditions and the application process, call 1-800-515-3784.

The HeartBeat program provides select fertility medications at no cost for cancer patients. To be eligible, you must be a female U.S. citizen or permanent resident with a cancer diagnosis who has not received chemotherapy within the previous six months. To learn more about terms and conditions and the application process, call 1-888-347-3415. (Residents of Arkansas, Massachusetts, or New Jersey can call 1-877-252-0553.)

If your fertility medications are manufactured by EMD Serono, read our previous post for an overview of EMD Serono’s patient assistance programs. You can also read our previous posts on managing the costs of fertility treatment to learn about additional financial resources, including Alto’s financial support for fertility medications:

Managing the Costs of Fertility Treatment

A Financial Planning Guide for Egg Freezing

We’re here for you during fertility treatment

At Alto, we understand that fertility treatment is a physical, emotional, and financial investment, and we offer support with all aspects of your fertility journey.

We prioritize your financial wellness, working with your doctor, your insurance (if applicable), and any third party savings programs that you may qualify for to make your medications as affordable as possible. In addition to automatically applying any coupon savings, we’ll connect you with any outside programs that require you to apply directly.

We’re here to help with the rest of the process, too, with free same-day delivery of your medications, temperature controlled packaging, and fertility resources like personalized injection guide videos and one-on-one consultations with fertility-trained pharmacists.

To get a price quote specific to your fertility medication protocol, complete our online form.

To automate a manual, error-prone pharmacy workflow, we turned to event streaming. Here’s what we learned from one of the first Kafka use cases at Alto.

How We Used Kafka to Build an Event-Driven Automation Pipeline and Scale Our Pharmacy

Imagine this: You're at the doctor’s office, and your doctor just wrote you a new prescription. Minutes later, before you even check out with the receptionist, you already have a notification from Alto Pharmacy on your phone that your prescription is ready. All you have to do is pick the date and time that works best for your free courier delivery.

This is the future we’re building at Alto: a future where a prescription can be transcribed, billed, and verified by a pharmacist in five minutes, flat. To get there without dramatically increasing Alto’s head count, we need to automate much of the process, starting with the first step: transcribing, or intaking, a prescription.

As a pharmacy, we receive prescriptions in many different forms. Some are sent electronically, in a structured format, but others are handwritten, phoned in, or even faxed. To represent all of these forms in a single table, we previously required every incoming prescription to be transcribed by an Alto team member, who would answer questions like:

Whom is this prescription for? Is this customer already in our system?

Where did this prescription come from? Who wrote it?

What is the relevant prescription information (medication to dispense, quantity, days supply, directions, etc.)?

This manual process is both time-consuming and prone to human error, which, if uncaught, could impact our ability to process the prescription downstream. Furthermore, at our busiest times, it could take up to two hours for a team member to get through the pending intake queue — unacceptable if we hope to have prescriptions ready to schedule before people even leave their doctor’s office. 

Automating intake required close collaboration between three teams:

Data Science, who built the decision-making algorithms 

Data Engineering, who served up the results of those algorithms

Product Engineering, who used those results to automatically intake prescriptions 

To allow the teams to operate in parallel without toe-stepping — and in the language most suitable for each (the Data Science and Data teams prefer Python, while product engineers work mainly in Ruby) — we separated the code into two environments: 

1. Data Prod Interface (DPI), where the code for generating automation results lives

2. Wunderbar (our proprietary pharmacy operations platform), where the code for requesting and using those automation results lives

The key question: to establish robust communication between these two environments, should we use an API-based approach, or an event-driven one? Each has its pros and cons. 

Legacy approach everyone at Alto is familiar with

Existing enforcement of strong types and data

Difficult to scale with increased data & requests

Requires ongoing authorization / authentication

Infrastructure relevant to other business areas

Automatic retries, reprocessing, and queueing

Our existing infrastructure currently utilizes a hefty API-based structure, so there was a natural tendency to go down this path, but we knew that beginning to migrate services towards an event-based architecture with Kafka at its heart would help us in the long term.

Kafka is a framework implementation developed by LinkedIn, now open-source with the Apache Software Foundation. It aims to provide a unified, high-throughput, and low-latency platform for handling real-time data feeds. 

Alto uses Amazon Web Services as our cloud provider, and luckily, they offer an out-of-the-box managed solution for Kafka, MSK. To configure Kafka with our system, our infrastructure team worked with AWS to set up managed instances to comply with our business requirements. Our Infrastructure team will share more details about this work in an upcoming blog post. 

Kafka offers many benefits. The asynchronous nature of the message system allows for retries, reprocessing, and queueing as well as easy recovery from outages. In addition, the infrastructure work done for setting up the managed cluster would be a one-off workstream. When complete, we’d be able to re-use the same setup and configurations across various business needs to streamline other projects that leverage Kafka. 

Setting up for success: defining a strict contract

Blog

The Medicare Donut Hole, Explained

Traveling With Diabetes: How to Prepare

Hello, Long Island!

Five Black Healthcare Leaders to Celebrate

How We Established Better Boundaries and Clearer Code Ownership at Alto

Next Steps After an HIV Diagnosis

A Guide to Ferring Pharmaceuticals’ Fertility Medication Savings Programs

How We Used Kafka to Build an Event-Driven Automation Pipeline and Scale Our Pharmacy

Tackling Technical Debt and Improving Security: How Alto Untangled an Overloaded User Model

What To Know About Insulin Pens

Hello Austin, We're Alto Pharmacy!

All About HIV: Stages, Symptoms and Treatment

Switch to a better pharmacy.