BCBS North Dakota · Heart Disease Risk Reduction

BCBS North Dakota coverage for Ozempic (Heart Disease Risk Reduction)

Employer / Commercial Insurance

Covered (preferred drug)

What you need to qualify

A1C of 6.5% or higher
Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

CV risk reduction via T2DM diagnosis pathway

All of:

Diagnosis of type 2 diabetes
A1C >= 6.5% confirmed by lab test or medical records
FDA labeled indication for CV risk reduction applies (established cardiovascular disease with T2DM)
Patient age is within FDA labeling for the requested indication, OR there is support for using the requested agent for the patient's age
Patient will NOT be using the requested agent in combination with a DPP-4 containing agent
Patient will NOT be using the requested agent in combination with another GLP-1 receptor agonist
Patient does NOT have any FDA labeled contraindications to the requested agent

Documentation to bring

Documentation of type 2 diabetes diagnosis
Lab test results or medical records confirming A1C >= 6.5%
Documentation of established cardiovascular disease
Confirmation patient is not using a DPP-4 inhibitor concurrently
Confirmation patient is not using another GLP-1 receptor agonist concurrently

Quantity limits

2 MG/3ML, 4 MG/3ML, 8 MG/3ML — 1 pen

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months

Not covered when

Concurrent use with DPP-4 inhibitor
Concurrent use with another GLP-1 receptor agonist
FDA labeled contraindications (personal or family history of MTC or MEN 2; prior serious hypersensitivity reaction)

Policy note: The PA criteria module does not create a separate pathway specifically for the CV risk reduction indication. The policy covers Ozempic under the T2DM diagnosis criteria module; the FDA-labeled CV risk reduction indication is acknowledged in the FDA indication table. CV risk reduction is covered under the same PA criteria as diabetes (T2DM diagnosis + A1C >= 6.5%). The policy references FDA labeling compliance as part of criteria (criterion 3.B.2). Specific CV risk reduction criteria (e.g., established CVD requirement, GDMT) are not separately enumerated in this PA module.

Policy effective May 11, 2026 · verified June 2, 2026 · source: ND_GLP1_PAQL_ProgSum.pdf

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