North Dakota Medicaid coverage for Ozempic (Heart

Medicaid

Covered with requirements

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.

MACE risk reduction - non-diabetic patients (Ozempic as step-therapy prerequisite for Wegovy injection)

All of:

Member is between ages ≥55 and <75
Member does not have diabetes, as evidenced by A1C within normal range without diabetes medication
Member has initial BMI ≥27 kg/m2 and <35 kg/m2
Member is concurrently taking lipid-lowering and antiplatelet therapy
Dose escalation to 2mg of Ozempic (semaglutide) must be tolerated before Wegovy injection will be authorized (2.4mg is the only strength indicated for reduction of MACE)

Plus any one of:

Prior myocardial infarction (MI)
Prior stroke AND peripheral arterial disease (PAD), as evidenced by intermittent claudication with ankle-brachial index <0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease

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

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