Visit www.allumaco.com/providers to review prior authorization submission options.

No. However, using CoverMyMeds, Surescripts or another electronic PA (ePA) submission tool will provide drug-specific questions that often support more timely determinations.

• ePA renewal requests can generally be submitted within 60 days of the prior PA’s end date.
• Override or exception requests for anything except prior authorizations may need to be submitted via fax (e.g., benefit exceptions).
• If ePA submission is not available to the submitter, requests can be submitted via fax.

In general, only one request is required per medication. Approved requests will typically allow coverage for other strengths of the same medication and dosage form.

• Within CoverMyMeds, use of the “Patient Insurance Search” option is recommended to ensure that the PA request is correctly routed to Alluma for review.
• It is also recommended that “ALLUMA” is entered in the “By Insurance Plan or PBM name” field to ensure the correct form is selected.

• It is highly recommended that clinical documentation be attached to all PA requests to ensure that information is available for a timely and accurate review and determination.
• If the required information is not included in the initial request, Alluma may request additional information or documentation via a fax request to the provider. Failure to respond promptly can lead to delays in processing or a denied request.

• Urgent requests are generally those for medications or medical conditions that, if subject to the time allowed for making non-urgent care determinations, could seriously jeopardize the life or health of the patient, the ability of the patient to regain maximum function, or which involve a medical condition that would subject the patient to severe pain that cannot be managed adequately without care or treatment.
• Inappropriately submitting PA requests as “urgent” may require Alluma to make a determination without being able to engage prescribers for clarifications or to solicit additional information. This may result in incomplete “urgent” requests being denied whereas they may have been approvable with time to request additional information.

• On average, Alluma renders a determination in less than one business day after a complete PA request is received.
• Failure to include complete information or required clinical documentation with a PA submission request is the most common reason for delay.

• When complete, prescribers will receive a copy of the determination letter via fax while members will receive a copy by USPS mail or electronic means (where applicable). Electronic notification may also be provided via the ePA tool used to submit the request.
• To check the status of a request, members are encouraged to visit their member portal and click the “Prior Authorizations” tab. Prescribers and members can also call the customer service phone number on the member ID card for additional information.
• PA requests that remain in process for more than two business days are generally awaiting additional information from the prescriber. Submitters are encouraged to visit the ePA tool to confirm that all questions have been answered. If the questions have been answered, Alluma may have requested clinical documentation. Alluma will send up to two requests for additional information before closing the case due to the lack of response.

• Plan-specific appeal filing timelines and procedures can be found in the plan’s summary plan description (SPD) or benefits booklet. Appeal instructions are also included on the initial adverse benefit notification provided to members and their providers.
• In general, it is recommended that:
  • Appeal requests be filed using the appeal filing form included with the initial adverse benefit notification.
  • Prior to submission, the requestor reviews the denial rationale in the original adverse benefit (denial) notification so that the specific reason(s) for denial can be clearly addressed in the appeal.
  • Clinical documentation supporting the appeal request should be included with the request. This may include recent clinical notes outlining the plan of care, pertinent lab values, prior medication or medical history, relevant clinical literature as appropriate, etc.

• Coverage for weight-loss medications varies by health plan. Some plans may provide coverage, while others may exclude medications used for weight management. When covered, medications may also be subject to prior authorization or other plan-specific requirements.
• Prescribers may call Alluma Customer Service at 800-818-9290 to confirm plan-specific coverage details. When calling, please have the member name, date of birth, member ID number, and name of the medication(s) available. This will help ensure that the appropriate coverage details can be reviewed.

• As outlined above, weight-loss medication PA requests should be submitted through an electronic prior authorization (ePA) platform such as CoverMyMeds or Surescripts. These platforms guide prescribers through the required coverage-criteria questions and help ensure that the necessary information is provided for review.
• If electronic submission is not available, PA requests may be faxed to 833-951-1683 using the prior authorization fax form available at allumaco.com/providers.

• To support timely reviews, the following clinical documentation (e.g., clinical notes outlining the plan of care, pertinent lab values, prior medication or medical history) should be included with PA submissions:
  • A current weight and body mass index (BMI) that was measured within the past 30 days.
  • For patients already receiving weight-loss therapy, the baseline weight and BMI (prior to beginning therapy with a weight loss medication)
  • When applicable, documentation of weight-related comorbidities and supporting objective findings such as lipid levels, blood pressure readings, or sleep-study results.
• Providing complete clinical documentation with the initial request can help avoid delays related to requests for additional information.

• Some health plans may require member participation in a digital weight-management program (e.g., Omada) or other plan-specific weight management program.
• Prescribers may call Alluma Customer Service at 800-818-9290 to confirm plan-specific coverage details. When calling, please have the member name, date of birth, member ID number, and name of the medication(s) available. This will help ensure that the appropriate coverage details can be reviewed.