CurrentColorado Rocky Mountain Health PlansPolicy N/A

Methyldopa prior authorization

This document defines prior authorization and medical necessity criteria for coverage of methyldopa under the payer's Clinical Pharmacy Programs, primarily governing pregnant members treated for hypertension.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMethyldopa prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2025

Next Review DateMay 1, 2025

Key ActionSubmit prior authorization showing the patient is pregnant and methyldopa is prescribed for hypertension.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration

pregnancyrequired patient condition

hypertensionrequired treatment indication

6/2023,5/2024,5/2025policy review dates

Coverage criteria — methyldopa

This policy limits coverage of methyldopa to use in pregnancy. Approvals will only be issued when the patient is pregnant and the medication is prescribed for the treatment of hypertension. Requests for methyldopa for non‑pregnant patients are not supported by this coverage criteria due to the drug's risk profile and limited utilization outside of pregnancy.

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Initial Therapy

Covered when ALL of the following are met

Initial approval conditions: Patient is pregnant

Authorization issued for 12 months per program rules

Initial approval conditions: Methyldopa is prescribed for treatment of hypertension

Authorization issued for 12 months per program rules

Provider actions and authorization rules

Prior Authorization

Prior Authorization Required

Prior authorization is required for methyldopa. Approval is granted only when the patient is pregnant and methyldopa is prescribed for the treatment of hypertension.

Approval requires documentation of pregnancy and diagnosis of hypertension (ICD-10).

Prior Authorization

Approval Conditions

Coverage is approved only when both of the following criteria are met.

Patient is pregnant.
Medication is prescribed for treatment of hypertension.

Step Therapy

There is no explicit step therapy requirement defined for methyldopa in this policy; however, approvals may be based on prior claim or medication history and program-specific automated processes.

Payer may approve based on previous claims/medication history, diagnosis codes, and claim logic.
No required trial of alternative agents is specified in this policy.

Documentation Required

Authorization Length and Supporting Data

Authorizations may be issued for up to 12 months and may rely on supporting data from claims and medication history, diagnosis codes, and other claim logic. State or federal mandates and the member's benefit plan may affect coverage.

Authorization length: up to 12 months.
Supporting data: prior claims/medication history, ICD-10 diagnosis codes, and automated claim logic may be used for initial approval and reauthorization.
Other applicable programs, federal/state requirements, and member-specific benefits may impact coverage determinations.

Background and clinical context

Methyldopa is indicated for the treatment of hypertension and is an aromatic‑amino‑acid decarboxylase inhibitor. The American Heart Association identifies methyldopa as a well‑established first‑line option for managing hypertension in pregnancy. Use of methyldopa outside pregnancy is limited because of significant adverse events, which informs the payer's decision to restrict coverage to pregnant patients.