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.

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.

Here’s what we know so far about the risk of COVID-19 for people with HIV, vaccine safety, and how to protect yourself from contracting COVID-19. 

What the COVID-19 Vaccine Means for Those With HIV

As of March, 2021, over 115 million people worldwide have been diagnosed with COVID-19. As the COVID-19 pandemic persists, many are wondering what the COVID-19 vaccine could mean for the 38 million people who are living with HIV: is it safe or does it pose a greater risk for these individuals? Here’s what we know so far about the risk of COVID-19 for people with HIV, vaccine safety, and how to protect yourself from contracting COVID-19. 

Are people living with HIV at a higher risk for COVID-19? 

Data is limited and experts are still learning exactly how COVID-19 affects those with HIV, but the Centers for Disease Control and Prevention (CDC) says that those who have HIV (and who are also on effective HIV treatment) generally have the same risk of contracting the virus as those who don’t have HIV. 

So, who is at greater risk? The CDC has evidence that shows older adults and people with certain underlying medical conditions like chronic obstructive pulmonary disease (COPD), type 2 diabetes, and a weakened immune system are at an increased risk for more severe cases of COVID-19. And since nearly half of those living with HIV in the United States are over 50 years old, those living with HIV are encouraged to follow all CDC guidelines to reduce the risk of COVID-19 exposure.

Experts have not found any significant evidence that those living with HIV will experience more severe COVID-19 outcomes; studies performed in Spain and in the United States on a Veterans aging cohort both found no difference in susceptibility to the virus in those with HIV.

Are COVID-19 vaccines safe for people living with HIV?

Yes. According to the United Nations Program on HIV/AIDS (UNAIDS), the COVID-19 vaccines currently being developed or approved by regulators are believed to be safe for most people, including those living with HIV. The COVID-19 vaccines, like other vaccines, undergo the same safety tests and are required to meet rigorous standards. 

Regulators have not yet found any evidence that people living with HIV are at a greater risk from the COVID-19 vaccine in terms of side effects than anyone else.

How does the vaccine work and what symptoms could I expect?

In a recent virtual town hall on COVID-19 and HIV hosted by Getting to Zero San Francisco, experts confirmed that the COVID-19 vaccine has been proven to help reduce the severity of illness from the virus. The vaccine could also prevent infection, reduce transmission, and lead to healthier communities. 

The COVID-19 vaccines work by helping our bodies develop immunity to the virus that causes COVID-19 without us having to actually contract the illness. The different vaccines work in slightly different ways to protect us, but all generally leave the body with a supply of cells that remember how to fight the virus in the future.

After receiving the COVID-19 vaccine, the process of building immunity can result in some people experiencing mild symptoms like a sore arm and mild fever or chills in the days following vaccination. If you have any pain or discomfort, you can talk to your doctor or pharmacist about over-the-counter medications.

How can people with HIV protect themselves from COVID-19?

As you’ve likely heard, the best way to keep from getting sick is simply to avoid exposure to the virus. Everyone, including people living with HIV, should keep taking everyday actions like wearing a mask, staying six feet away from those who don’t live with you, and avoiding crowds, to help avoid contracting and spreading COVID-19.

If you have HIV and are taking your HIV medicine, it’s important to continue doing so and follow any advice from your healthcare provider. This will help keep your immune system healthy and ready to fight off any infection. The CDC also recommends lifestyle practices like eating healthy foods, getting at least eight hours of sleep per night, and minimizing stress as much as you can.

If you develop any symptoms that indicate you might have COVID-19, the CDC recommends calling your healthcare provider and getting tested. Most people have mild illness and can recover at home. If you do develop severe symptoms, the CDC recommends you get emergency medical care immediately.

At Alto, we’re committed to ensuring you receive you medications safely and on time throughout the COVID-19 pandemic. Our pharmacy locations are fully stocked and our pharmacists are on hand to answer any questions and provide ongoing access to support and advice. Reach out to our HIV specialty team at 1-800-874-5881 (call/text) or send us a message through our mobile app. 

Expires 04/01/2021

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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.

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

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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 nearly 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 most 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.

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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"

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FAQs

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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

What the COVID-19 Vaccine Means for Those With HIV

An HIV Prevention Milestone: Truvada Goes Generic

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.