Methyldopa — Prior Authorization / Medical Necessity
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Defines prior authorization and medical necessity criteria for coverage of methyldopa under Clinical Pharmacy Programs for Colorado Rocky Mountain Health Plans members.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Coverage Criteria
Covered when ALL of the following are met
Authorization will be issued for 12 months per policy.
Use of methyldopa outside of pregnancy is not supported by this policy. The source document notes that methyldopa has limited utilization outside of pregnancy and is associated with significant adverse events, so policy coverage is limited to pregnant patients treated for hypertension.
Methyldopa use in non-pregnant patients for hypertension is considered not medically necessary under this policy. Approval is limited to cases where the patient is pregnant and the medication is being used to treat hypertension; requests for non-pregnant indications would not meet the stated coverage criteria.
Initial Therapy
Initial Therapy
Initial approval
UnitedHealthcare may approve initial authorization based solely on previous claim/medication history, diagnosis codes (ICD-10), and/or claim logic.
Reauthorization / Continuation Criteria
Reauthorization
Reauthorization
Authorization will be issued for 12 months per policy.
Billing, Codes, and Authorization Duration
| No codes listed |
Prior Authorization, Documentation, and Provider Requirements
Prior authorization required for methyldopa in pregnancy
Methyldopa requires prior authorization. Approval is granted only when the patient is pregnant and the medication is being used to treat hypertension.
No step therapy required
This policy specifies no step therapy requirements for methyldopa.
Submit prior medication history and accurate ICD-10 codes
Approvals may be issued based on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic; submitting accurate diagnosis codes and prior medication history supports authorization.
- UnitedHealthcare may approve initial and reauthorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic.
Denial risk if pregnancy or indication not documented
Requests that do not document the patient’s pregnancy and that the medication is being used to treat hypertension may be denied.
Site-of-Care Restrictions
No site-of-care restrictions
No site-of-care (office) restrictions are specified in this policy.
Definitions
Background and Clinical Context
Methyldopa is described as an aromatic-amino-acid decarboxylase inhibitor indicated for treatment of hypertension. The American Heart Association recommends methyldopa as a widely established first-line option for hypertension in pregnancy. The policy therefore limits coverage to pregnant patients when the drug is used to treat hypertension, reflecting both the clinical guidance and the drug's safety profile outside pregnancy.
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