North Dakota Medicaid coverage for Wegovy (Heart

Medicaid

Covered with requirements

What you need to qualify

Age 55 to 74
BMI of 27 or higher
Prior trial of another GLP-1 medication (Ozempic and Rybelsus)
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.

Wegovy injection for MACE - requires Ozempic 2mg step therapy

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

Wegovy tablets for MACE - non-preferred, requires 12-month semaglutide injection trial

All of:

All initial MACE criteria above must be met
Member must have failed a 12-month trial of semaglutide injection, as evidenced by paid claims or pharmacy printouts
Dose escalation to 14mg of Rybelsus (semaglutide) must be tolerated before Wegovy tablets will be authorized

Plus any one of:

Unable to achieve weight loss ≥5% from baseline
Unable to achieve reduction of BMI ≥5% from baseline
Experienced a cardiovascular event following a 5% weight loss or 5% BMI reduction since starting medication

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)
For Wegovy injection: documentation of dose escalation to Ozempic 2mg tolerated
For Wegovy tablets (non-preferred): documentation of 12-month failed trial of semaglutide injection; documentation of Rybelsus 14mg tolerated

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, Failure of Wegovy tablets (for renewal/non-preferred step) 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% BMI reduction since starting medication, and staying on a maintenance dose of at least 2.4 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Patients WITH diabetes are excluded from this MACE indication (must use diabetes criteria)
BMI ≥35 kg/m2 is excluded
Only the 2.4mg strength is indicated for MACE reduction

Policy note: Wegovy injection and Wegovy tablets are both listed as NON-PREFERRED agents in the MACE section. Wegovy injection requires prior dose escalation to Ozempic 2mg as step therapy. Wegovy tablets are non-preferred relative to injection and require a 12-month trial of semaglutide injection with documented failure. For tobacco users, cessation counseling in past year required. BMI range is ≥27 and <35 kg/m2 - upper limit of <35 is notable and more restrictive than typical.

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

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