In this interview, Alto's third engineer shares how her background and experiences, from her nomadic upbringing to serving as student body president in college, led her to where she is today at Alto.

Building an Engineering Career at Alto 

This interview has been edited for length and clarity.

Elnaz joined as Alto’s third software engineer in 2016, coming from Lob. She has since gone on to shape Alto’s culture and recruiting efforts and rose to become an Engineering Manager. In this interview, she shares how her background and experiences, from her nomadic upbringing to serving as student body president in college, led her to where she is today.

You’ve lived in 8 cities spanning 5 countries and 3 continents! Tell me more about that and how it shaped you?

My family started moving around from a really early age. My dad was a chemical engineering professor in Iran for around 25 years. When my siblings started going to college in the United States, we started moving around to pay for their college tuition. He did a sabbatical in Australia (where I learned English!), a short stint at his alma mater Oklahoma State, time at a research institute in Kuwait, and a few other locations. 

As a result, I’ve been exposed to such extremes in my life in moving from the Middle East to Oklahoma, or between Chicago and San Francisco. I’ve just been exposed to such a variety of people that’s allowed me to both blend in with a lot of different folks, but also be able to be a bridge and a translator. Regardless of whether it's in work or my personal life, I think “passionate” is maybe the most consistent way I would describe myself. I'm either passionate about the work I'm doing or passionate about getting outside for camping and traveling. There's an intensity in all aspects of my life. 

From my past roles, I realized I loved working on cross-functional problems. I stumbled across Alto, eventually realizing that working cross-functionally was such a unique and fundamental opportunity with this company. We would not succeed if engineering sat in one corner and operations in another - we had to work together. The other piece was that I knew I wanted to work on something more meaningful. I felt like I was able to close the loop on what started off my career – working in civic tech and on public interest projects – and do that as a more effective person in the healthcare business. Finally, I wanted to learn more about the business side of things. What I learned in my first job out of school was that nonprofits and civic tech are great, but they don’t work unless you can fund them. I really wanted to find businesses that were viable and also added value.

You were Alto’s third engineer. What was that like?

In retrospect, it was fantastic. I was able to shape the culture, see the evolution of the company, and develop a lot of relationships. For example, I was really passionate about engineering being a partner to the rest of the organization and for us to go into the trenches to understand how the frontlines use our product to figure out how to make things better. I was given a lot of unique opportunities, including working on recruiting to make sure we were building a more equitable interview process, and also ensuring that folks are successful once they got here. I was able to influence Alto’s diversity and inclusion efforts and grow as a leader to pave the path for more people after me.

How was the transition from engineer to management like for you?

The first feeling was just sheer excitement. So much of what I’d been passionate about up until then had been done on the side: building an onboarding program for new hires, building out better interview questions, improving our on-call process. Becoming a manager was validation of how things that I'm good at are not just pure engineering skills, but also things that make engineering more effective. I'd been worried about being perceived as not technical enough, or that the soft skills didn’t matter, and it really validated that what I wanted to work on was valued. The second feeling was, “How do I actually know if I'm doing a good job?” I think that's one of the hardest things when you first become a manager. 

As an engineer, you have these tight feedback loops: you build something, the test runs, and you see the product and the impact. As a manager, you might have a conversation or make one comment to someone only to find out months later what the actual impact of that comment was on the person. I had to get accustomed to slower feedback loops and being more comfortable with less structure.

You were your college’s student government president. Tell me more about that and how it relates to what you do now?

What I quickly learned from that position was that defusing tense situations was my superpower. When there were disagreements between the students and the university, I felt like I could speak to both sides and bridge the gap. That was the first time I really began to appreciate my upbringing of having been exposed to a lot of different cultures and different people. This becomes relevant in basically every intersection at work: how engineering and operations relate to each other, how engineering and design relate to each other, or being able to see different perspectives within the same discipline. 

In particular, I think it was helpful for me to spend time with a design and development firm because I saw the anxiety that designers can have around not solving the problem at the core or being forced to make sacrifices about the fidelity of their solution. Now when I'm working with a designer I make sure they understand when I’m talking about velocity, but I can also put that hat aside and talk about what's possible given a longer timeframe. 

What’s the best piece of advice you’ve ever received?

I've always felt like I've seesawed between coming on too strong or being too shy. The advice I received was to not think about them as binary aspects, but rather celebrate that I have both of those attributes. So when I was weighing the idea of whether I’m really great at people management, does that make me less of a technical person? Or if I'm technical, does that mean I can't be good at the people side of things? I think this advice was really helpful for me to stop seeing it as an either-or choice and recognize I can be great at both. It makes me think of a clip of Dave Chappelle where he talks about advice that his mom gave him that really resonates with me. His mom told him, “Sometimes you gotta be a lion so you can be the lamb you really are.”	

What are you most excited about at Alto in the next year?

Personally, I’m most excited for my parents to be able to use Alto as we expand our service areas so they understand what I've been doing the past three years! Professionally, I'm excited about the big dent we can make in technical scalability, as well as making it easier for our operations team to provide a consistently excellent patient experience.

If you have any questions about Alto, or are interested in joining our team, please reach out via LinkedIn.

Senior Manager, Engineering at Alto Pharmacy

We took the best parts of the software engineer interview process from the places we’ve previously worked and interviewed, eliminated stuff we thought wasn’t relevant, and added our own special Alto ingredients!

What to Expect When You Interview as a Software Engineer at Alto

Thank you so much for considering an interview at Alto! At Alto, we’ve devoted a considerable amount of time refining how we interview candidates for software engineering roles. As engineers, engineering managers, and recruiters at a rapidly growing company, this is a big part of our jobs and we want to get it right: for the candidate, for ourselves, and for the team. We took the best parts of the interview process from the places we’ve previously worked and interviewed, eliminated stuff we thought wasn’t relevant, and added our own special Alto ingredients. Let’s dive in!

What does a Software Engineer at Alto do?

First and foremost, Alto exists to serve our patients--whether that be via building products, or providing exemplary service. Engineers at Alto are empowered to go the extra mile to make an impact for our patients, medical providers, and amazing pharmacists and care professionals. We are organized into small mission-focused teams where you will be working closely with Product Managers, Designers, Data Analysts, Data Scientists, and our Care team. Alto Engineers enjoy this cross-functional, collaborative environment where everybody has a voice in the direction of the product and the team. Compared to other companies, we are more end-user focused in most of our teams, even those that work primarily on platform and infrastructure.

Our pragmatic focus on impact includes making sure that we fulfill our company value of Patients Come First. We have a strong culture of code reviews, testing, documentation, and knowledge sharing to ensure that the service consistently meets our patients’ and providers’ expectations for quality and reliability.

Developing a Predictive Interview Process to Reduce Unconscious Bias

We want our engineering team to look like our customers — and we strive to serve everybody. Our mission is to fulfill medicine’s true purpose — to improve the quality of life — for everyone who needs it. In order to effectively carry out our mission, we believe our engineering team should reflect the rich diversity of our customers. Our engineers come from all backgrounds and took many varied paths to arrive here: self-taught, coding bootcamps, and top-tier universities. Prior experience ranges from none to decades at large public tech companies with many joining from other startups and consulting/contracting backgrounds. Reflecting this, we’ve put together an interview process that focuses on predicting job success over testing for rarely-used computer science knowledge and encourages hiring diversity of all kinds rather than filtering for a certain type of engineer.

Throughout the interview, we work on problems that are facing Alto today or that we’ve dealt with recently. Our interview questions rarely have a “right” answer, and if you are writing code, any language works. (We spend our time mostly in Javascript, Ruby, and Go.) Occasionally, you will have more than one interviewer in the session. This is likely because one interviewer is shadowing the other to train, get calibrated, and learn how to deliver and interpret the questions while minimizing bias.

This is a quick chat with a recruiter or a hiring manager to further expand on your experience, capabilities, and interests. Based on this, we’ll have a good idea for which team(s) you would be the best match.

This screen aims to validate your technical skills. You’ll be working in a networked IDE (like CoderPad) with an Altoid (what we call ourselves) to write and run code that addresses a typical problem that you might face at Alto. We’re looking for fluency in the language of your choice and some fundamental object-oriented programming design skills. 

This is based on a typical task that you might face at Alto - something like designing or interfacing with an API. You're welcome to use StackOverflow, Google, or any other resources at your disposal—including your interviewer! We’ll be observing how you understand the problem, communicate with your interviewer to develop requirements, and get to working and well-tested code. 

In this section, you’ll spend some time getting to know a problem we have faced. You’ll spend 10-30 minutes working on how to approach and optimize a challenge that impacts our business everyday, then show that you can translate that into working code.

This module varies depending on your experience and interests. For some folks, we dive deeper into software design and learn how you would break up a hypothetical application into core modules. For senior frontend developers, this might be an app architecture challenge. And for senior backend developers, we’ll address systems architecture with an eye toward scalability, observability, and technology choices. In every case, we’re looking closely at how you approached the problem, gathered requirements, and justified your decisions.

The Engineering Manager is trying to deeply understand who you are as an engineer and a person. What do you get excited about? What type of roles do you like taking on within a team or project? What is your career arc and how can you best advance that at Alto? The questions often asked are behavioral or hypothetical in nature, and we love to hear stories about your proudest accomplishments and challenges you’ve overcome.

“I had an amazing interview experience with Alto - although the recruiters were super busy, they made sure to accommodate my timeline," shares Jacinda Zhong, Software Engineer, Core Services at Alto.  "I was really pleased to find out that Alto asks questions based on the type of work I’d be doing - no obscure CS concepts, and questions centered around complex business logic that you’d encounter working at Alto. Before my onsite, my recruiter gave me a call to provide context on what they’d be asking. No gotchas and no surprises, plus lots of detail so that I could be prepared to do my best. So excited to be working here and contributing to a great mission!”

The interviewers get together promptly—we try to do it no later than the next day—to discuss next steps. Prior to our discussion, we individually assess your performance against a rubric that takes into account your level of experience and the requirements for the role.

There is rarely unanimity in the panel. Almost everybody at Alto was discussed in a panel where there were some mix of Yeses and Nos. Often, we ask ourselves questions like, “What is the candidate’s superpower?”, “What will they add to the team?”, and “For which open role are they the best match?” Our hardest decisions are the ones where we all agree that the candidate is somebody we want to work with but we don’t have exactly the right role.

Don’t be surprised if your interview is slightly different from what is described here. We’re constantly refining our process to get to better hiring decisions more quickly and with less bias with regular feedback from candidates, interviewers and recruiters. 

Have you had an interview experience that you thought was exceptional? Let us know at feedback@alto.com.

Why Mission-Driven Software Engineers Hold the Key to Alto’s Continued Success

Alto is the world’s most people-centric pharmacy. Our goal is not simply to distribute medications but to improve health outcomes and quality of life. What’s more, we want to make those improvements accessible to everybody.

To get to that point, we need to understand what is preventing people from accessing all the benefits medicine has to offer. We believe it’s especially important to address non-adherence, which is when people don’t take medications as prescribed. Non-adherence is a national problem that causes 125,000 avoidable deaths per year (more than three times the number of car accident deaths) and $300 billion in avoidable medical costs (more than half the money spent on pharmacy as a whole).

It also means learning how to scale our technology and processes to bring our products to a bigger swath of the population. To achieve both of these things, we need to first scale our engineering team.

Because of our unique business model, Alto is positioned to pursue three exciting growth vectors:

New Therapeutic Specialties: In addition to our general pharmacy capabilities, we have developed specialized expertise and infrastructure for managing complex treatments like fertility, dermatology, HIV, psychiatry, and other therapies that come with sticky coordination issues and unique considerations. We have made it easier than ever for people to navigate these treatment areas, but there is more we can do. Our team has identified 26 additional treatment areas that could benefit from specialized technology and processes. Mastering those areas is high on our to-do list.

New Geographic Markets: By expanding into the top 50 U.S. cities, we could potentially serve 55% of the country’s population. If we expand to the top 100 cities, our coverage would increase to 70%.

New Clinical Partnerships: Alto facilitates coordination between our team, healthcare providers, insurance companies, and the people taking the medications. In the process, we improve workflows and health outcomes. That offers a powerful benefit to clinics, medical groups, and hospital systems. Because of that reputation, we currently have a waiting list of healthcare providers who want to partner with us. That’s more demand than we can keep up with, which isn’t such a terrible problem.

When Opportunity and Demand Exceed Capacity

Alto is in a fortunate position. It is rare among companies to have multiple compounding growth vectors and a reserve of would-be partners angling for our product. We are not demand constrained, we are operationally constrained, and even then, we continue to double our business every six to nine months — just not as quickly as our potential promises.

Scaling up as a means of reaching our potential is an exciting challenge we’re already tackling. In late 2018, we closed our Series C, giving us the fuel we need to build out our engineering team and develop the technology and processes that will make our continued growth possible. That work will entail fleshing out each of our existing product areas, scaling them, and identifying and solving even more deep-rooted industry issues through better technology and better processes.

Currently, Alto boasts a small but talented and agile engineering team staffed by individuals who honed their experience at some of the biggest names in tech like Facebook, Google, Uber, 23andMe, MIT, Stanford, and Berkeley. All of our engineers are relatively senior, so everyone has autonomy and ownership over their projects. It’s a collaborative, supportive, mission-driven environment, which is how we’ve been able to build so much in a relatively short period of time.

Up until now, we have been deliberate about keeping the team small, but we’ve reached an inflection point. In the next 18 months, we’re looking to increase the engineering team four-fold. With our new team in place, we will be in a great position to focus on our objectives: building and perfecting our operational efficiencies and product scalability.

We’re approaching the challenge of scalability from a few angles:

One is automation. We want to take the algorithms that are in our employees’ heads and put them into code, so they can focus more on caring for patients rather than logistics. We’ve done a bunch of automation work already, but there’s a lot left to do.

We’re also intent on designing tools to help our own team be more efficient with their time, which will mean better UX, better UI, more batching, and less context switching.

The third angle is self-service, and it’s the one we’re focused most intently on. Right now, there is significant human interaction between our team and consumers because we want to make sure consumers have the information they need to make optimal healthcare decisions. In our next phase of growth, we want to automate that process without losing any transparency or depriving a consumer of any agency, no matter their technological competence.

Essentially, we want to build the pharmacy version of TurboTax (without the part about lobbying to keep the system broken). With the right prompts and information, TurboTax walks users through the U.S. tax system, which is huge and complicated. In effect, the user becomes totally self-servicing. We want to do the same for the people who use Alto. That said, not everybody is proficient or comfortable with technology. In the spirit of accessibility and inclusivity, it will still be important that everyone who uses Alto also has the option to speak to a real, knowledgeable, and friendly person to get their questions answered and needs met. We have a responsibility as a healthcare provider to take care of all our patients, no matter how tech-savvy they might be, but for these patients we can still use technology to enable our team to get the patient the best possible option, quickly and easily.

Our engineering team is working toward products with even more expertise built in. In the process, we will also make our operations more efficient and more scalable, unblocking barriers to expansion in existing markets, new markets, and new verticals.

When we succeed at that alignment, we stand to change the nature of the industry. To get there, we will continue to grow our engineering team with right-fit, world-class talent that not only has the skillset to take Alto to the next level but also the values to keep us aligned and mission-driven in the process.

Learn more about Alto’s company values and mission-driven work culture.

You see your doctor and he or she writes you a new prescription, sending it electronically to your pharmacy of choice. You then receive a call from your pharmacy and the copay is much higher than you anticipated.

Your jaw drops. You find yourself thinking that something must be wrong with this calculation. How did your doctor think you could afford this drug?… Did the pharmacy apply your insurance correctly?… Is this for a whole year’s worth of medication?

If you find yourself in this situation, you are not alone.

There isn’t one simple answer to this question, but hopefully this article will help you understand the potential causes of a high copay and recognize which one might apply to you. The following are the most common reasons for a high copay:

If you notice your prescription drug costs escalate at the beginning of a new year, your deductible is the most likely culprit. With a deductible, patients will pay the majority of the cost of their medications out of pocket until a certain dollar amount has been reached. This amount varies significantly by plan and can range anywhere from the low hundreds to thousands. Once you hit this set amount, your typical copays will return and remain until the start of the next calendar year.

Copayment or drug coverage tiers are a way that insurance companies categorize drugs, and those from higher tiers will most likely cost you more than those from a lower tier. For instance, a brand name drug in Tier 3 will cost you more out of pocket than a generic alternative in Tier 1. Speciality drugs, or those prescribed as treatment for rare or serious medical conditions are commonly at the highest tier, and therefore, are also the most expensive. It is important to note that not all prescription insurance plans utilize tiers, and tiers differ immensely across various plans.

3. The drug requires a Prior Authorization

Oftentimes, insurance companies will reject claims for specialty, brand, or expensive medications without a Prior Authorization in place. A Prior Authorization, or PA, is an appeal process that, if accepted, will result in your Insurance covering a portion of your prescription costs. A PA may require your doctor to submit prerequisite therapy information and diagnosis, and ultimately, justify the reason he or she is requesting this treatment for you.

The important thing to note about PAs is that many drugs that require PAs are also more costly and specialized to begin with, which may affect your out of pocket cost even after it is approved by your insurance.

A formulary is a list of drugs which are covered in some part by your Insurance plan. Each plan has a unique formulary, which you can locate online or by calling your plan. If a drug is not on your “open” formulary, you may have the option of submitting a PA; however, if you have a “closed” formulary, a PA will not be approved. Your pharmacy will be able to inform you on your options and if you have an “open” or “closed” formulary. One thing to keep in mind is that formularies may change without warning, and a medication you are currently taking may be fully covered ($0 copay) one day and not covered, or covered with a copay the next.

We have seen this occur many times with birth control medication, for example, where a patient has been taking one brand for months with $0 copay, and all of a sudden she is subject to a $25 copay for the same medication. In this instance, the formulary has changed, and her Insurance plan is now requesting she takes a different brand, or generic equivalent of birth control medication.

5. You are in the “donut hole” (Medicare Part D only)

The “donut hole” or coverage gap, is specific to Medicare Part D participants, and means there is a temporary limit on what your plan will cover. The gap begins after you and your plan have spent a certain amount towards covered medication for the calendar year. For instance, this number in 2017 is $3,700. Once you are in the coverage gap, you could pay up to 40% of the plan’s cost for covered brand name drugs, and will pay 51% of the cost for generic drugs. These percentages may change year after year, and your costs incurred will add up over time to get you out of the coverage gap. You can find more information and specific examples of the coverage gap on the Medicare website.

Fortunately, you may have a couple options to cut your costs. If your doctor prescribed a brand name medication and there’s an alternative available, you may have the option of filling this instead. If the doctor requires that specific medication, talk to him or her about why, or ask your pharmacist to follow up for a new prescription. If an equivalent generic does not exist, there still may be a comparable substitute, which you should discuss with your doctor or pharmacist.

In the case of a Prior Authorization, your doctor can submit documentation to your insurance company explaining why this specific treatment is necessary. At Alto (formerly ScriptDash Pharmacy), we initiate this process with your doctor and track its progress, as well as notify you along the way.

A third way to lower your out of pocket costs, perhaps significantly, is to apply a manufacturer’s copay savings card. These savings cards are typically found with more expensive brand name medications and are accepted for the most part after your commercial insurance has paid for a portion of the medication. Lo Loestrin Fe, for instance, has a savings card that will bring down out of pocket expenses to $25 for a 28-day supply, which can be much lower than your initial copay when you only use your insurance. At Alto, we make this process easy on you and will actively search for, and apply, any savings cards for which you are a candidate.

While this isn’t an exhaustive list of everything that could contribute to your copay, it covers the majority of cases we see here at Alto. If you have any questions on what your insurance covers, you can always contact us for help. Alternatively, you can learn more about your insurance coverage by calling the number on the back of your card or by looking up your formulary online. We hope this takes some of the guess work out of deciphering your copay and will help you make more informed healthcare decisions in the future!

Deciphering Your Copay — What Your Pharmacy Isn’t Telling You

Our mission is to fulfill medicine’s true purpose — to improve quality of life — for everyone who needs it.

Patients come before all other stakeholders, including our teammates and our bottom line.

Every time we have to make a choice, we will always choose the well-being of our patients.

We work because we care, not because it’s expected of us.

If patients are happy and healthy, our business will be too.

Be reliable. It’s more important to be good for all than to be great for some.

Every patient puts their life in our hands, so we have a moral obligation to provide high quality care.

When difficult situations arise, we go above and beyond to make sure our patients are taken care of.

Before every interaction, pause and place yourself in the other person’s shoes, be it a patient, provider, or teammate.

Strive to deeply understand the thoughts and feelings of the people you interact with.

Patients are at their most vulnerable when interacting with us. Always try to understand their context.

Choose the work that makes the biggest impact toward our goals.

Always strive to understand the impact your work will make.

Prioritize impact over activity. Hard work alone won’t get us closer to our mission — only real results will.

Being right matters. It’s how we make the most impact.

Start from first principles and question underlying assumptions. There’s nothing sacred about the status quo.

Follow the scientific method: hypothesize, test, analyze, and iterate off a failed hypothesis to find the right solution.

Recognize when you’re wrong to get to right faster. Be open to changing your mind.

Be introspective. Your own strengths and weaknesses are important variables.

We are students of the industry. We learned to be a caring community pharmacy from AG, and we will stay true to our roots.

We’re not above other players in the industry who care. We support anybody who aligns with our mission to help patients.

Every Alto employee has important expertise, regardless of their role, tenure, or seniority.

To Alto’s CTO, an ethical, altruistic, supportive workplace is everything.

Every morning (ok, most mornings), I wake up motivated — eager, even — to get out of bed and go to work. But it’s not because I am some super-performing success-bot. This is not another blog post about a c-level executive’s otherworldly, highly-meticulous-yet-seemingly-effortless morning routine, and I have no prescriptive regimen for staying happy and mindful while still managing to “get it all done.” I only have one piece of advice, but it is one that has served me (and my mornings) well:

Work with people who share your passion and values.

At Alto, the company I co-founded in 2015, everyone, from me (the CTO) to product engineers to part-time prescription couriers, is dedicated to the same mission and vision. Every day, we strive to improve health outcomes by optimizing technology and processes to become the world’s most people-centric pharmacy. I am never not excited to work alongside the few hundred Alto employees that daily act in concert to support the success of our company and make a difference in the lives of people who use Alto.

Underlying this relentless drive toward mission and vision is a set of shared core values that defines our internal culture:

Patients come first — even before our bottom line and industry partners. We will always prioritize the wellbeing of the people who use Alto to manage their prescription medications.

Leave no person behind. It’s more important to be good for all than to be great for a select few.

Start with empathy. We strive deeply to understand the thoughts and feelings of everyone we interact with.

Focus on impact. We prioritize impact over activity and focus on the work that makes the biggest strides toward our goals.

Think rigorously. We’re open to changing our minds and never hesitate to question assumptions and first principles. There is nothing sacred about the status quo.

Be humble. Our work — however expert, technical, or specialized — is in service of our team, the people who use Alto, and the greater good. Everyone’s contributions count, and no one is too important to take out the trash, so to speak. And we are certainly not above other players in the industry whose mission to help patients aligns with our own.

For me and my teammates, it’s extremely fulfilling to contribute to this smart, caring, talented team working tirelessly to help so many people. Everyone’s role is different but invaluable, and our efforts have real meaning. I can say with confidence that working in this environment makes a huge difference in how I carry myself, because I know from previous professional experiences what the opposite looks and feels like.

When my co-founder Matt and I started Alto in 2015, we were both software engineers at Parse, a Facebook-owned company. Having spent years in Silicon Valley, we were already jaded by the tech ecosystem and were ready for a change. In thinking about what we wanted to pursue next in our lives, we noticed that other companies were not working on society’s most meaningful problems; they were focused on catering to the 1%. In contrast, we wanted to use our time and skills to build something that makes a tangible, positive impact on the daily lives of all people, especially those ignored by the tech industry.

And so, we found ourselves drawn to healthcare — a big, broken industry that affects most people negatively, especially the underprivileged. We did a lot of research to figure out what our wedge into healthcare would be, and pharmacy jumped out to us. Essentially, pharmacy is the healthcare industry’s consumer product, and consumer products just happens to be our area of expertise.

If you think about it, pharmacy is a product not unlike Facebook; almost everybody in the country uses at some point in their life. But evidence suggests it’s generally a bad one. The net promoter score of chain pharmacies is somewhere in the vicinity of -10. That’s shockingly bad. (For reference, American Airlines has a net promoter score of four.) Our research also found that more than 35% of all medications sent to pharmacies are never picked up as a result of some upstream issue.

It became clear to us that none of the pharmacy incumbents thought of themselves like a product, and especially not one that is consumer focused. None of them had the mindset to prioritize and optimize the user experience, which is the mindset Silicon Valley applies to photo-sharing apps and ad optimization tools and all sorts of other products we aren’t so passionate about. Instead, pharmacy incumbents focus on extracting value from the system and pushing the cost off onto patients. In that gap, we saw opportunity — and a moral imperative.

Today, Alto is making pharmacy convenient, accessible, and user-friendly. We make it easy for consumers to get information on their medications so that they can make informed healthcare decisions. To get there, we have built and continually work to improve a robust set of user-facing and internal tools to guide consumers through the complex and often barrier-laced process of prescription procurement, payer authorization, and medication fulfillment.

Because health outcomes are what we care about, we’re not pushing pills for profit. We are just as happy if a patient pursues an alternative therapy so long as it is in his or her best clinical interest. Our unique business and operational models make that possible.

In disrupting an industry that can be predatory to the most vulnerable among us, I am proud to say Alto attracts some of the most ethical, altruistic talent I have ever worked with. They make coming to work a pleasure and a privilege, and that makes all the difference, not just in my mornings but also my professional satisfaction and overall well-being. If any of that resonates with you, you might be just our type.

"Work With People Who Share Your Passion"

How Alto Pharmacy provided support and peace of mind during my embryo freezing process

I’m 33 years old and have been married for three years. I don’t have any children yet, but have always known I wanted a family. I have spent much of my career working in healthcare and have most recently worked at an education startup. I’m passionate about doing work that empowers women.

Many of my friends have gone through the egg freezing process, and my husband and I visited a clinic last year to learn more about our own fertility health and to explore the option of egg freezing as a future backup plan. The clinic we chose uses Alto for their fertility pharmacy services and referred me once we decided to go through a round of embryo freezing.

I had a great experience with Alto. The entire journey of learning about fertility preservation, deciding whether or not to go through with a procedure, and then starting the process is really stressful and often left me feeling like I needed a lot more information and guidance than was readily available. With Alto, everything about getting my prescriptions filled and finding answers to my questions was straightforward and dependable.

At my very first appointment, the clinical team decided to start me on medications that same night. I signed up with Alto, and they delivered my medications same-day within the span of a few hours. The customer service reps at Alto were really helpful and worked with an urgency that I appreciated given how out of control I felt in that initial phase of the treatment plan.

What I liked most about Alto was how dependable they were. When you’re going through a fertility preservation process, your prescription and medication needs change every few days for the duration of the treatment. There were several times where I got a prescription in the morning from my physician and needed to get the delivery that same day. Each time, Alto did a great job of making sure the medication was processed, scheduled for delivery and delivered on time. I didn’t have to stress that something would go wrong and the whole process would be messed up.

I also found that I could rely on Alto to help fill knowledge gaps about what was happening with my care. Each delivery included documents to explain exactly what the medications were for, something that wasn’t always clear when I got a prescription from the doctor. I appreciated Alto’s focus on customer service. They proactively reached out to give me updates about what to expect next, ensure my questions were answered, and even did small gestures like including a few caramels in each delivery that, while small, were appreciated.

I used to have a chronic disease, chronic idiopathic urticaria (hives), that required a specialty medication, and I had a really difficult time dealing with pharmacies and ensuring I got my medication correctly. I had to see one doctor to prescribe the medication, go in person to pick up the medication at a specialty pharmacy and then drive it in a cooler to a second, different doctor to administer it. With Alto, it was so much easier and straightforward to make sure I received my medications when I needed them, without having to leave home.

Alto was easy to work with and dependable which is so important and helpful. While the outcomes of my procedure were not what I had hoped for, I have no complaints at all with my experience with Alto. I would definitely recommend Alto to a friend considering egg freezing or IVF treatments.

Alto is the West Coast’s leading fertility pharmacy with more than 15,000 patients served. We’re open evenings and weekends, offer free delivery seven days a week, and will always work to help you find the best price. Interested in using Alto’s services for your fertility medications? Ask your doctor to send your prescriptions to Alto or give us a call at 1 (800) 874–5881.

This post was written by Rebecca G., a San Francisco Bay area operations and community builder, and Alto fertility patient.

How My Experience as an IVF Coordinator Showed Me the Importance of Alto’s Care Model

I knew from a very young age that I wanted to work with moms and babies. My mother ran a daycare from our home throughout my childhood, and for my sixth grade report on “what I want to be when I grow up,” I interviewed a well baby RN at a local hospital. After completing my Bachelor’s degree, I started working as front desk staff at a fertility clinic and I knew immediately that I had found my spot. I could work with soon-to-be moms and new moms every day.

I quickly shifted from the front desk to being a Medical Assistant for a physician where I was able to participate in ultrasounds, retrievals and transfers. The first time I was in a pregnancy ultrasound and heard a baby’s heartbeat, I was in tears and overcome with emotion. Eventually I transitioned into the role of IVF Coordinator where I was a key part of a patient’s — and their partner’s — journey to building a family.

I really got to know my patients — in fertility, you become a trusted confidant. Their loss is your loss, and their win is your win. While you might not bring your work home physically, emotionally the job never really leaves you — IVF coordinator was the most emotionally taxing job I’ll ever have. But each time we received a positive pregnancy test, it made up for all the ups and downs.

Alto’s model shouldn’t be so revolutionary, but it is. Clinics and patients don’t have to be okay with today’s standard pharmacy experience — Alto offers a fundamentally better model.

Fertility pharmacy plays a key role in a patient’s fertility journey. Medications need to arrive on time, in the correct assortment, with all necessary ancillary supplies. Often, the decision to change a dose or initiate a trigger shot means that medications are needed that same day or on the weekend. As an IVF coordinator, helping my patients make a decision about pharmacy was tricky — each pharmacy option offered some of the service qualities I was looking for, but no pharmacy offered all of the things I wanted for my patients. Remembering which pharmacy checked which boxes was really challenging.

It was so important to me that my patients were taken care of and receiving the highest quality of care. When they had questions, I was always available and responsive, even in the evenings and on weekends. What was most frustrating about working with fertility pharmacies was that when I’d send a prescription out, I’d have no control over the quality of the patient’s experience with the pharmacy.

For my patients, I wanted a pharmacy option that was accessible, responsive, cost conscious, and accountable for making sure nothing was getting lost or off track. For my clinic team, I wanted a pharmacy partner that didn’t require me to micromanage everything about a patient’s medications. I hated being the middle person between the patient and the pharmacy. The first time a pharmacy [Alto] came in and told me I could send any patient with any insurance to them and they would triage it, I thought, “We’ll send everything to them.”

Alto Pharmacy’s patient care model checked all those boxes. When I first heard about their same day delivery, evening and weekend hours and benefits coordination, it sounded too good to be true. Having access to a local fertility pharmacy with same day delivery was simply unheard of.

But if this was all true, it was clearly something that I wanted to be a part of. I knew from my experience as an IVF coordinator that this model served a crucial need for both patients and their care teams. I wanted to bring my knowledge and experience to help make the Alto care model even better than it already was.

What I quickly learned after joining Alto Pharmacy to help build partnerships with fertility clinics was that while same day delivery is extremely practical and necessary in fertility, it’s our patient care team that is the most standout quality. Our patient care staff have the same drive and commitment to helping build families that initially drew me to work in fertility. They genuinely care about the success of the treatment and making sure that the patients are being taken care of. This focus on the patient is unmatched in the pharmacy space — fertility pharmacy is not a truly personalized experience anywhere else but Alto.

The patient care team consistently goes above and beyond to make sure that patients have what they need, when they need it, so that cycles aren’t interrupted. Those same-day medication changes and trigger shot decisions mean that our team is processing late notice prescriptions and frequently staying late to get deliveries out the door. Many members of our patient care team have even driven medications direct to patient’s homes so that cycles stay on track. They know how much going the extra mile is going to relieve the patient’s stress.

What I like to tell people is that we haven’t found some magical secret sauce at Alto — we didn’t create texting, or mobile apps — but pharmacy has been behind the times for so long compared to many other industries and especially within healthcare. Alto’s model shouldn’t be so revolutionary, but it is. Clinics and patients don’t have to be okay with today’s standard pharmacy experience — Alto offers a fundamentally better model.

Alto is the West Coast’s leading fertility pharmacy with more than 15,000 patients served. We’re open evenings and weekends, offer free delivery seven days a week, and will always work to help you find the best price. Interested in using Alto’s services for your fertility medications? Ask your care team to send your prescriptions to Alto or give us a call at 1 (800) 874–5881.

Tina Simon is a Fertility Partnerships Manager for Alto Pharmacy in the San Francisco Bay area.

The View from Both Sides of the Fertility Pharmacy Experience

Healthcare is complicated, but managing your medications doesn’t have to be.

With holiday travel, family engagements, and end of year insurance submissions, December brings with it both excitement for the new year and a lot of housekeeping. Alto takes the hassle out of pharmacy by making pharmacy convenient and fast — no more standing in line or adding an extra stop to your evening commute. Get a question answered or schedule your next medication delivery with a few quick clicks online or over the phone with the assistance of our friendly Care team.

We’re always adding new features to both the mobile and desktop app experiences to save you valuable time, give you control over your medications, and provide transparency into what really goes into pharmacy. Cross “pharmacy” off of your year-end to-do list with the newest features in our app.

Download your FSA receipts: No need to keep a paper receipts folder or try to remember which medications you filled when. Alto keeps track of the details so you don’t have to. Your year-end FSA receipts are now available for easy download from both the desktop and mobile apps under “Payment Details.”

Set up a linked bank account: Alto’s commitment to transparency means more choices and more control. In addition to payment via credit or debit card, you can link a bank account to automatically save 1% off every order.

Manage your family’s medications: Eliminate extra trips to the pharmacy and confusion around refill cycles. Set up a family account to view and manage medications for you and your family members from a single account:

View medications for your whole family from one med list

Schedule medications for any family member in one delivery

Request refills and prescription renewals on behalf of your family members

To manage your family members’ medications, you’ll need to link them to your account. Contact our patient care team at 1 (800) 874–5881 to quickly get set up.

New to Alto? Here’s what you can expect from the full Alto app experience:

View all of your current and archived prescriptions along with detailed medication information

Access price information for each medication, including insurance, coupon, and cash pay prices so you always know your options

Schedule deliveries for the date and delivery window of your choice — delivery is always free!

Request refills and enroll in our auto-refill program

Securely message a pharmacist with questions, including in the evenings and on weekends

We want to know what you think about these new features! Email us at feedback@alto.com.

Take Control of Your Prescriptions With New Features in the Alto App

Anna left her doctor’s office with a glimmer of hope. For months, Anna had been struggling with digestive issues and now her doctor had suggested they try a promising new medication. Finally, she thought, maybe this new medication could provide some relief and her life could return to normal. But when Anna arrived at her pharmacy, she was shocked to discover the medication would cost $400 per month! The pharmacist at the counter explained that if she couldn’t afford the copay, she would need to call her insurance or her doctor to “figure it out.” Frustrated and overwhelmed, Anna left the pharmacy empty-handed and with the distinct feeling that healthcare had been designed to work against her.

Unfortunately, Anna is not alone in encountering obstacles that prevent her from getting the medication she needs. From the moment we leave the doctor’s office, we are thrust into a maddening, depersonalized system that feels like a big black box. We are left to navigate it all on our own, especially when it comes to medication pricing. 1 in 3 Americans admit that they aren’t taking the medication they need because of cost. This is not only harmful to our long term health as patients, but also a devastating cost to our country. It is estimated that there are 125,000 avoidable deaths per year and nearly $300 billion in downstream medical costs due medication non-adherence. You may have heard stories of diabetic patients who, faced with climbing insulin costs, died from skipping doses or resorting to cheaper alternatives. For these patients and their families, getting the right medication is an issue of life or death. And for many like Anna, it’s, at the very least, very high stakes.

Today, medication pricing is set by multiple stakeholders in a process that is entirely hidden from patients and doctors:

Your employer contracts with a pharmacy benefits manager (or “PBM”, like Caremark, Express Scripts, etc.) whose job is to determine which medications should be covered or not under your insurance plan (even down to the exact dosage and brand that your doctor prescribes).

The PBM negotiates with the drug manufacturers to agree upon a specific price to charge the employer for a medication, the remaining copay for patients, and the PBM’s hefty cut for administering the service. It’s not hard to imagine how commercial incentives might color decisions on which medications are covered and how they are priced.

Drug manufacturers also offer copay assistance programs for select medications, with varying eligibility criteria, but these are marketed primarily through doctors, meaning patients often don’t know these assistance programs exist or if they qualify.

Today, none of this data is transparent or shared. These parties (doctors, drug manufacturers, PBMs) do not have the incentives nor the technology in place to coordinate with one another to act in the patient’s best interest. Drug manufacturers and pharmacies get paid by the medications dispensed, doctors get paid by the appointment/procedure, and PBMs get paid through taking a hefty cut of the negotiated medication price. These parties are naturally incentivized to pursue a path that delivers the highest financial return with the least amount of effort. Sitting in the center of this web, pharmacies are uniquely positioned to coordinate the best outcome for the patient. Traditional retail pharmacies, however, don’t have access to technology solutions that would easily bridge the gap between insurer, manufacturer and physician. It’s no wonder medication prices continue to climb and the process of getting medication remains so inefficient.

At Alto, we asked ourselves, “What if every patient could have a pharmacy expert on standby to help him/her navigate the complex world of medication pricing?”

We believe that pharmacy’s role is to make the process work around patients, rather than asking patients to learn how to work the system. So we built a modern pharmacy software platform that enables our Alto pharmacists, billing specialists and patient advocates to coordinate between doctors and insurance companies to ensure patients have clear choices and transparency on medication pricing.

Alto is the first pharmacy to proactively:

Show patients the price of a medication both with and without insurance, within minutes of receiving their prescription. These prices matter because sometimes the price without insurance is actually cheaper.

Match patients with savings and copay assistance programs offered through drug manufacturers. Often, patients and doctors don’t have time to manually keep track of these programs, so our service automatically searches for eligible programs.

Help patients and doctors navigate the complexities of insurance, whether by identifying an alternative medication that is more affordable under the patient’s plan or helping to petition insurance to cover the medication (a process called Prior Authorization). Compiling all the paperwork and medical history data required by these insurance processes takes up valuable time from doctors (estimated at 20 hours of work per week per doctor). Our technology automates this process so patients can quickly get access to the medications they need.

Here’s what all this means for a patient like Anna:

When Anna told her doctor about the expensive copay, her doctor sent the prescription to Alto. Anna’s doctor knew that Alto would help with the paperwork needed to petition insurance to cover a patient’s medication. Within a few hours, Anna received a notification from Alto that they’d worked with her doctor to start the process with her insurance. In the meantime, Alto had matched her with a program from the drug manufacturer that would reduce her copay so she could get started on her therapy right away. When her first Alto package was delivered that evening, Anna regained that early glimmer of hope, relieved to have the Alto team in her corner. Within days, Anna’s insurance approved the coverage, and Anna has been able to stay on the medication, better managing her symptoms (and her medication costs) for over a year now. Anna has been able to focus on her health and feel some semblance of her new “normal.”

Since Alto Pharmacy opened four years ago, we’ve had the privilege to help hundreds of thousands of patients and physicians. By harnessing the power of our pharmacy team and our technology, patients get access to the best medications, at the best possible prices, delivered to their home the same day. 

We are proud to be cracking open the black box surrounding medication pricing and giving Alto patients a new level of transparency and control in their health journey. And we are hopeful that with increased awareness and patient advocacy, systemic changes are on the way that will help make medications more accessible and affordable for everyone.

Monica Tran has led the Product and Design team at Alto for two years, helping build a suite of products for pharmacists, physicians and patients that allows Alto to break down barriers to medication access and transform the pharmacy experience. She recently transitioned into a leadership development and coaching role, helping to scale Alto’s organization, values and patient experience.

Breaking Open the Black Box of Medication Pricing

Update from the Alto team, March 17th, 2020: 
As the spread of COVID-19 continues to impact daily routines in the communities we serve, Alto remains open and ready to deliver your medications safely to your door. Our pharmacy locations are fully stocked, our couriers are ready, and our pharmacists can assist with coordinating early refills and longer fills to ensure you have access to your medications throughout this period. Reach out to our care team at 1 (800) 874-5881 (call/text) or via secure message on our mobile app. Delivery is always free; we're here to help.

Worried about coronavirus? 
Here’s what our pharmacists want you to know.

As the news continues to unfold about COVID-19 (also known as coronavirus) and its spread in our communities, you’re likely making preparations for you and your family’s medical needs.

Our pharmacists are here to help. Here are their recommendations for staying healthy, but we also recommend following guidance from the Centers for Disease Control and World Health Organization and checking their sites regularly for updates.

COVID-19 spreads much like the common cold or flu. The virus that causes COVID-19 is passed from person to person through close personal contact (things like touching or shaking hands), coughing, sneezing, or touching a surface with the virus on it and then touching your eyes, nose or mouth without washing your hands.

Though everyone is at risk for becoming infected, elderly patients and patients with diabetes, hypertension, and cardiovascular disease have been shown to be at higher risk for severe symptoms. This may change as we understand the disease more.

Symptoms range greatly and can begin to appear two to fourteen days after exposure. Fever and cough are the most common, although some individuals will have no symptoms and others may experience severe difficulty breathing and other respiratory issues. Given that this outbreak coincides with cold and flu season, it may be difficult to differentiate between the diseases.

Wash your hands! Often, vigorously, and with soap and water for at least 30 seconds. If soap and water aren’t available, use alcohol-based hand sanitizer.

Avoid touching your face with unwashed hands. 

Disinfect surfaces and commonly used objects regularly with bleach or chlorine.

Avoid close personal contact with people who are sick or who may have been exposed to the virus. Stay away from work, school or other high-traffic areas if you begin to exhibit symptoms like fever and cough.

Alto’s free home delivery service and automatic refills mean you don’t have to add worrying about your medication supply or going out in public to your list of precautionary measures. We’ll make sure you have the prescriptions you need on schedule. Stocking up on cold medicine or other over the counter medications? Our pharmacists can add those to your next delivery.

Our team is available 9 am - 9 pm PT Monday - Friday and 10 am - 6 pm PT on weekends; reach out via phone, text or the app.

If you think you’ve been exposed to COVID-19, contact your healthcare provider via phone or other digital means. Do not go to your healthcare provider’s office in person if you believe you may be exhibiting symptoms from exposure as public health officials will need to coordinate necessary precautions for staff and other patients.

Blog

Alto's Mission & Values

New Articles

Too stressed to sleep? These strategies can help.

All about PrEP for HIV Prevention

What to Consider When Selecting a Fertility Pharmacy

COVID-19

To Your Health: Updates to Alto’s Free Same-Day Doorstep Delivery

Re-creating a Community Pharmacy in the Time of COVID-19

Engineering at Alto

What to Expect When You Interview as a Software Engineer at Alto

Building an Engineering Career at Alto

Why a Software Engineer Turned Down 8 Other Offers to Join the Alto Team

"Work With People Who Share Your Passion"

Are You Right for Alto?

Fertility

My Fertility Preservation Story

The View from Both Sides of the Fertility Pharmacy Experience

Health

Tips for Navigating Birth Control Costs

From Your Pharmacy: What You Need to Know About Coronavirus

Products

New From Alto: Medication Reminders & Auto Refills

Take Control of Your Prescriptions With New Features in the Alto App

Company

Announcing Alto’s Advisory Board

Hims & Hers Partners with Alto for Same-Day Prescription Delivery for Primary Care Patients

Culture

Alto's Head of Talent Shares His Personal Health Journey

Delivering the Best Care: Why a Veteran Pharmacist Chose to Join the Alto Team

Industry

Breaking Open the Black Box of Medication Pricing

Deciphering Your Copay — What Your Pharmacy Isn’t Telling You

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