Does North Dakota Medicaid cover Ozempic?

What you need to qualify

• A1C no higher than 7%
• Prescribed by or in consultation with a specialist
• Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Evidence of inability to achieve goal A1C (≤7%) or TIR (>70%) despite 90-day trial of triple combination therapy (Ozempic + metformin + SGLT-2 inhibitor or insulin), evidenced by paid claims or pharmacy printouts
• Prescriber attestation of consultation with endocrinologist or diabetes specialist, OR documentation of diabetes education from diabetic specialist, educator, or pharmacist

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Member must have experienced and maintained clinical benefit since starting treatment; must continue to meet initial criteria; must be at least 80% adherent to medication (or provide clinical justification for non-adherence with a plan to improve).

Not covered when

• DPP-4 inhibitors and GLP-1 agonists are not payable together (therapeutic duplication)
• GI intolerances typically will not be considered to bypass trial requirements (specific mitigation steps required first)

Policy note: Ozempic (semaglutide) is a PREFERRED GLP-1 agent for diabetes - NO PA required. Non-preferred GLP-1 agents (Trulicity/dulaglutide, liraglutide/Victoza) require PA after failure of triple therapy including Ozempic. For GI intolerance to Ozempic: chart documentation must be submitted showing dietary changes, reduction in meal size, prescription antiemetics, and dose adjustment were trialed for at least two months before bypassing. Rybelsus (semaglutide oral) is also a preferred GLP-1 agent per PDL (no PA required). Note: The document states 'Ozempic and Victoza (brand) are covered without prior authorization by submitting diagnosis code T43.505A, T43.505D, or T43.505S if being used for antipsychotic-induced weight gain' under Weight Loss section.

Policy effective April 1, 2026 · verified June 3, 2026 · source: PDL-2026.4.pdf

What you need to qualify

• Age 55 to 74
• BMI of 27 or higher
• Established cardiovascular disease (MI, stroke, and PAD)
• On guideline-directed medical therapy (lipid-lowering therapy and antiplatelet therapy)
• Lab results confirming eligibility
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• A1C lab result within normal range (confirming no diabetes) without diabetes medication
• Documentation of baseline BMI ≥27 kg/m2 and <35 kg/m2
• Documentation of qualifying CV event (prior MI; OR prior stroke AND PAD with ABI <0.85, revascularization, or amputation)
• Documentation of concurrent lipid-lowering therapy use
• Documentation of concurrent antiplatelet therapy use
• Tobacco cessation counseling documentation (if current tobacco user, within past year)
• Documentation of dose escalation to Ozempic 2mg tolerated (required before Wegovy injection authorized)

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for at least 5% weight loss from the starting weight, at least 5% reduction in BMI, and For Wegovy injection: must have tolerated dose escalation to 2mg of Ozempic before Wegovy authorized. Failure defined as: unable to achieve weight loss ≥5% from baseline, OR unable to achieve reduction of BMI ≥5% from baseline, OR experienced a cardiovascular event following a 5% weight loss or 5% reduction of BMI since starting medication. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Patients WITH diabetes are not eligible for this MACE indication (diabetes exclusion); they should use the diabetes criteria
• BMI ≥35 kg/m2 is excluded from this MACE indication
• Ozempic 2mg is required as step therapy before Wegovy injection for MACE

Policy note: Under the 'Reduction of Major Adverse Cardiovascular Events (MACE)' section, Ozempic is listed as a NON-PREFERRED injectable agent (Wegovy injection and Ozempic are both listed; Wegovy injection is also non-preferred; Wegovy tablets are non-preferred). For diabetic patients qualifying for MACE reduction, the document directs to the diabetes category criteria. The MACE section specifically addresses non-diabetic patients. Ozempic 2mg must be tolerated as a prerequisite step before Wegovy injection for MACE is authorized. The BMI range is ≥27 and <35 kg/m2.

Policy effective April 1, 2026 · verified June 3, 2026 · source: PDL-2026.4.pdf

No additional clinical requirements are listed beyond the diagnosis.

Qualification pathways

You can qualify through any one of these.

Policy note: Under the 'Diabetic Kidney Disease' section, Ozempic (semaglutide) is explicitly listed as a GLP-1 receptor agonist with NO PA REQUIRED. This is a separate formulary listing from the diabetes GLP-1 agonist section. No specific CKD severity criteria (eGFR, UACR) are stated for Ozempic in this section - it appears to be covered without PA for diabetic kidney disease. Kerendia (finerenone) in the same section requires PA and specifies eGFR ≥25 and UACR ≥30 mg/g criteria, but those criteria apply to Kerendia, not Ozempic.

Policy effective April 1, 2026 · verified June 3, 2026 · source: PDL-2026.4.pdf