In this post we’ll define what a prior authorization is, 3 tips to plan for them, and how Alto provides support in the process.

What is a Prior Authorization?

Imagine going to your doctor’s office and receiving a treatment plan only to learn that your medication or procedure needs approval, commonly referred to as a prior authorization (PA). This might seem odd given that your physician recommended your prescription or procedure as the best option. However, the approval isn’t required from your doctor but rather your insurance company. This is to ensure that the treatment complies with their coverage standards. 

A prior authorization is a request to your insurance company for coverage of certain medications or medical procedures. You can think of a prior authorization as the “green light” to proceeding with your physician’s recommended treatment plan. Insurance companies typically require this approval process for the following situations: 

Medications that may be misused, abused or have adverse effects

Medications that are new to market and not yet listed on insurance formularies (i.e. may be at a higher cost than other drugs that are similar/more cost effective) 

Medications that your doctor prescribed to treat a condition other than those officially approved by the FDA, also known as "off-label use”

Medical treatments or procedures where medical necessity requires assessment

Why are Prior Authorizations so Important?

A recent study shows that 1 in 4 doctors believe the prior authorization process has a disadvantageous effect on their patients’ well-being due to delays caused in treatment. Despite this, prior authorizations remain a key part in gaining insurance approval. Put simply, this is their way of “gatekeeping” cost effective coverage appropriate for each patient. 

At Alto, we understand why insurance companies want extra due diligence on expensive or risky medications, but we don't think patients should have to navigate this complicated world on their own. And these hurdles/hoops should never substantially delay access to treatment. That’s why we proactively file prior authorizations when they are needed, ensuring there are no delays. In fact, we have a dedicated support team who works closely with your doctor’s office the moment a prescription comes in that requires approval. We’ll also always keep both you and your physician in the loop throughout the process so you know the current status of the request. 

Ask your doctor if a prior authorization might be necessary when discussing treatment 

Consider a pharmacy, like Alto, that is action-oriented in filing prior authorizations (and we offer this support for free!)

Don’t be discouraged by the process. While this might be an extra step it’s likely to save you from paying full-price. 

Regardless of whether or not you may need a prior authorization now, it’s helpful to understand what to expect so that you are prepared. In the event that the prior authorization request is denied, we will work directly with your doctor to either process an appeal or find covered alternative treatments so that you don't have to. 

In some cases such as fertility medications, we will help you to understand your out-of-pocket costs and to identify alternative sources of financial assistance to ensure you're getting the best possible prices. Gaining access to your medications isn’t limited by a prior authorization, and with the right pharmacy partner you can feel confident that you’ll have an advocate on your side. 

Questions about Alto or our cost savings approach? 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.

We want to support you in preparing for your best health. PrEP, or pre-exposure prophylaxis, is an HIV prevention method that's available by prescription. Learn more about who should take it, how effective it is, and possible side effects.

All about PrEP for HIV Prevention

PrEP, or pre-exposure prophylaxis, is an HIV prevention method that's available by prescription. It isn’t a vaccine, though its purpose is similar. It’s a pill that’s taken every day to protect you from infection if exposed. 

With consistent use, the medicine remains present in the bloodstream of an HIV-negative individual. Then, if they’re exposed to HIV, it will block the invading virus from spreading throughout their body. 

According to the CDC, PrEP has been shown to reduce the risk of getting HIV from sex by 99% with consistent use. And it can even reduce the risk for intravenous drug users by 74% if taken daily.

Anyone who is HIV-negative and at risk for HIV infection can choose to take PrEP. PrEP may be right for you if you have a partner who is HIV positive or you do not know their HIV status, are a man having sex with men, are a trans masculine person having sex with men, are a trans feminine person having sex with men, have sex without condoms, are a sex worker, use injection drugs, or are concerned about HIV infection. Your healthcare provider can let you know if PrEP is the right choice for you.

There are currently two FDA-approved medications for PrEP: Truvada® and Descovy®. Both are oral medications that are only available by prescription. Your doctor will let you know which is best for you. Since PrEP should only be taken by those who are HIV-negative, you will need to take an HIV test before you can receive a prescription and also every three months while you’re taking it. You will also need to take a general blood test every six months. Staying on PrEP is a commitment, but these follow-up appointments are crucial for your health. 

Not all providers and health clinics offer PrEP,  but HIV.gov maintains an HIV Services Locator that will help you find a provider near you. 

Telemedicine is an option that can also make the process more accessible—and many more healthcare providers are offering remote consultations. Telehealth services allow you to schedule a phone or video consultation with your healthcare provider then use at-home test kits to complete any required testing through the mail. Talk to your healthcare provider to learn more about this possibility. 

PrEP is usually covered by most insurance plans, including Medicaid. There are also patient assistance programs that can help you access PrEP at a low cost or even free. The Gilead Advancing Access® program offers a copay coupon card for those with insurance and a Medical Assistance Program for those who are uninsured. They’ll help you find out if you’re eligible and may be able to suggest alternative sources of financial support if you are not. If you’re not sure if your insurer will cover your prescription, our team is here to help. We can inquire on your behalf and ensure you get the lowest price. 

Some people may experience side effects like nausea, diarrhea, headaches, and dizziness, however, they usually subside over time. Serious side effects aren’t common, but you should tell your provider if you notice any unusual symptoms. Your doctor will also be monitoring your blood work.

No—and this is important. PrEP needs time to build up in your bloodstream before it can effectively fend off an HIV infection. It will take a period of continuous use (usually at least one week or one month) before it is fully effective, so talk with your doctor about your specific time frame. If you’re engaging in sexual activity, be sure to use another form of protection in the meantime. You can also speak with a pharmacist at Alto if you have questions about how your medication works. 

And remember—if PrEP isn’t taken every day, there may not be enough of it present in your body to prevent infection. It’s extremely important to be consistent. Also, PrEP only protects against HIV infection, so you’ll need to continue using condoms to protect against other sexually transmitted infections (STIs). 

We recommend talking it over with your provider. If they do write you a prescription for PrEP,  the team at Alto can support you through the process of obtaining your medication. Our pharmacists are always here to answer your questions, from how to take it to what to do if you miss a dose. We’ll also deliver your prescription for free, send you quarterly lab reminders, and show you how to use the Alto app to set up daily reminders to take your pill. 

If it’s right for you, the decision to take PrEP is an important commitment to your health and well-being. We’ll be here to make sure the next steps are as easy as possible. 

We want to support you in preparing for your best health. Our team is available 9 am - 9 pm PT Monday - Friday and 10 am - 6 pm PT on weekends; call or text 1-800-874-5881, or download the mobile app for secure 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 other qualified health provider with any questions you may have regarding a medical condition.

This October, a generic version of Truvada became available in the United States for the first time. In this article we'll explain what these means for PrEP users and how Alto can help.

An HIV Prevention Milestone: Truvada Goes Generic

The world of HIV prevention medications is still relatively new. In 2004, Truvada roared onto the scene and drastically changed the future of HIV. While the medication was initially used to treat HIV, in 2012 the FDA approved its use as a form of pre-exposure prophylaxis (PrEP), a daily prescription medication that prevents HIV infection.

When taken as prescribed, Truvada is 99% effective at preventing sexually transmitted HIV infection. It has been shown to potentially cause decreased kidney function and a small amount of bone loss in some individuals. Though studies indicate these side effects are slight, they present a barrier for people with pre-existing renal and bone density issues. Descovy, an updated form of PrEP, was introduced last year with research showing kidney and bone safety improvements over Truvada. 

Truvada and Descovy are both patented and manufactured by Gilead Sciences. Both are considered highly effective, safe, and well-tolerated by most PrEP users. While Descovy is less likely to cause unfavorable changes in kidney and bone blood tests, Truvada has been shown to have a more favorable impact on blood fat levels and lead to less weight gain. The FDA has not yet approved Descovy for cisgender women or transgender men—more studies are still needed. Those who are uncertain which medication is right for them should discuss the options with their healthcare provider. 

For more on PrEP, read “All about PrEP for HIV Prevention.”

This October, a generic version of Truvada became available in the United States for the first time. Why the delay? When a brand-name medication enters the market, it is protected by patents and granted a period of exclusivity. Now that Truvada’s exclusivity period has ended, manufacturers with generic alternatives may seek approval from the FDA. 

Teva Pharmaceuticals was the first manufacturer to receive FDA approval for a generic version of Truvada. More generic versions will likely follow in 2021, increasing competition and driving down the price. 

Curious about how medication versions work? Read “What’s the Difference between Generic and Brand-name Medications?”

By lowering the cost of PrEP, the emergence of generic Truvada will ultimately put less strain on the U.S. healthcare system and help make PrEP more widely accessible to those at risk of HIV infection. Those who switch to generic Truvada will likely see their out-of-pocket costs decrease; however, there may be consequences for people who prefer Descovy—the newer formulation of PrEP.

In the wake of generic Truvada’s arrival, some insurance companies have decided to stop covering Descovy due to higher costs. While the two forms of PrEP may well be interchangeable for many patients, Descovy is not identical to Truvada. A small subset of people may have less desirable outcomes if compelled to switch versions by their insurers. People who need or prefer Descovy, especially because of preexisting renal or bone density issues, will likely need to obtain prior authorization approval and could face higher out-of-pocket costs. 

At Alto, we specialize in handling prior authorizations and performing thorough cost savings investigations. If we notice a change in your out-of-pocket cost, we’ll let you know, and we can work to identify ways to save you money. Here’s a closer look at how your pharmacy, healthcare provider, and insurance company work together to manage your prescriptions. 

How Insurance Companies Manage Medication Costs

Unsurprisingly, insurance companies tend to favor the cheapest version of a medication with similar efficacy. One way insurers encourage less expensive alternatives is through prior authorizations—a restriction that requires doctors to request that the insurance company cover certain medications. Not every prescription is subject to a prior authorization, but it’s commonly used when a doctor prescribes a brand-name drug with a generic available. The doctor must prove to the insurer why the specific version they prescribed is medically necessary. 

In most cases, prior authorizations are intended to ensure the safest and most cost-effective medication is used. However, they often require extensive paperwork and multiple phone calls from doctors’ offices, which can become a drain on time and resources for busy offices and clinics or cause delays in getting your prescription. 

For more on how the process works, read, “What is a Prior Authorization?”

Finding out that you need a prior authorization can feel daunting, but the right pharmacy partner will navigate the complexities for you. At Alto, we proactively file prior authorizations when they’re needed, taking the weight off the shoulders of both you and your doctor. We have a dedicated support team that works closely with your doctor’s office to obtain approval from your insurance company, and we’ll keep you updated throughout the whole process. 

After securing approval, we’ll conduct a thorough price investigation to identify sources of financial assistance and ensure you're getting the lowest possible price. We do all of this at no cost to you—we believe everyone should have access to the medications they need at an affordable price.

If you’re concerned about continued coverage for your preferred form of PrEP, we’re here to offer support. Our HIV specialists and care team are available from 9 am - 9 pm PT Monday - Friday and 10 am - 6 pm PT on weekends through secure messaging in our mobile app, or by texting or calling 1-800-874-5881. 

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.

Expires 04/01/2021

Specialty Pharmacy

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

Alto Pharmacy Technician

Alto Pharmacist

We’ll deliver all of your medications in the right order, at the same time. And all new patients receive a clinical check-in call from our pharmacists to make sure you’re on track and in control.

Whether you’re prescribed antibiotics or antivirals, our team is here to walk you through any side-effects, answer your questions, and get you on the path to optimal health.

Breathe a little easier knowing that Alto will remember you need to refill your rescue inhalers...even if you don’t.

Alto also stocks medications for rheumatology, multiple sclerosis, gastroenterology and cardiology. Transfer your prescription today to let us take care of you.

"Alto was a lot easier and always a lot more reliable than going to the pharmacy"

My medicine doesn’t seem to be working.

This acne medicine is upsetting my stomach.

When you have questions about side effects, or are worried about missing a dose, or not sure if you’re administering it correctly — we’re here to lend a hand.

With Alto, you won’t have to fight the lines at the pharmacy. Our couriers hand-deliver your medication to your door, whenever and wherever you need it.

Ask your doctor to send your prescription directly to Alto or ask us to transfer refills from your old pharmacy. We’ll look for any savings, including coupons and assistance programs, and reach out when it’s time to schedule your free delivery.

Yes. As a full-service pharmacy, Alto can fill all medications, including specialty, over-the-counter, brand, and generic. Alto’s pharmacists have deep expertise in many clinical areas, including heart and lung health, diabetes, fertility, HIV/PrEP/HRT, and more.

Yes. We accept all major insurance plans, including government-administered plans, and always work to get you the lowest price. Please note that coverage varies by state. For up to date information on coverage in your area call us at 1 (800) 874-5881.

We coordinate with your doctor to help you manage a wide range of conditions, everything from arthritis to asthma to HIV.

#000000

#0b4a72

Alto pharmacy has experts in every aspect of care, from everyday issues to complex conditions. General Health. Diabetes. Heart Health. Sexual Health. Specialty. Try Alto today!

Your doctor’s orders are ours, too.

We’re specialists in medication for:

HIV

Hepatitis C and Infectious Diseases

Asthma and COPD

And more

"Alto was a lot easier and always a lot more reliable than going to the pharmacy"

Ask your pharmacist, not the Internet.

Free hand-delivery to your door.

FAQs

How does Alto work?

Do you carry my medication?

Will I be covered by my insurance?

Switch to a better pharmacy.

Your doctor’s orders are ours, too.

We’re specialists in medication for:

HIV

Hepatitis C and Infectious Diseases

Asthma and COPD

And more

"Alto was a lot easier and always a lot more reliable than going to the pharmacy"

From Our Blog

An HIV Prevention Milestone: Truvada Goes Generic

All about PrEP for HIV Prevention

What is a Prior Authorization?

Ask your pharmacist, not the Internet.

Free hand-delivery to your door.

FAQs

How does Alto work?

Do you carry my medication?

Will I be covered by my insurance?

Switch to a better pharmacy.