North Dakota Medicaid and GLP-1 coverage

The state's manual lists the weight-loss drugs it pays for, and they are all older orals. Under "Anorexia, weight loss, and weight gain," the manual states: "Agents covered for weight loss are phentermine, bupropion, naltrexone, and topiramate" and "Agents covered for antipsychotic induced weight gain include Victoza and metformin." The same manual states that "All Medicaid (traditional and expansion) pharmacy claims as well as Special Health Services (SHS), AIDS Drug Assistance Program (ADAP), Russell Silver Program, and some county jail claims are processed by the ND Medicaid pharmacy system."

North Dakota Department of Health & Human Services, Medical Services Division, Pharmacy Provider Manual, effective June 2026 · source

The drug list's obesity section names four drugs and no GLP-1. Under "Weight Loss," the heading "Obesity" reads in full: "The following drugs are covered without prior authorization by submitting a corresponding diagnosis code for the indication: phentermine, bupropion, naltrexone, topiramate." A separate heading, "Antipsychotic Induced Weight Gain," states that "Ozempic injection 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." Across the whole 702,652-character document, Zepbound is named exactly once — in the sleep-apnea section — and Saxenda is not named at all.

North Dakota Department of Health and Human Services, Medical Services Division, Pharmacy Coverage Policy Manual — Preferred Drug List, Version 2026.6, effective July 2026 · source

The heart-risk criteria have a ceiling as well as a floor, on both age and BMI. Approval requires that "The member is between ages of ≥ 55 and < 75," that "The member does not have diabetes, as evidenced by A1c within normal range without diabetes medication," and that "The member has an initial BMI of ≥ 27 kg/m2 and < 35 kg/m2" — so a BMI of 35 or above fails these criteria. The member must also have had a "Prior myocardial infarction (MI)" or a "Prior stroke and peripheral arterial disease (PAD)," must be "concurrently taking lipid-lowering and antiplatelet therapy," and, if a current tobacco user, must have had cessation counseling in the past year. Wegovy is reached only through a step: "If the member qualifies for Wegovy injection, a dose escalation to 2mg of Ozempic injection (semaglutide) must be tolerated before Wegovy will be authorized." Wegovy is non-preferred in this class; Ozempic injection is preferred. Approval runs twelve months.

North Dakota Medicaid, Pharmacy Coverage Policy Manual — Reduction of Major Adverse Cardiovascular Events (MACE), effective July 2026 · source

The sleep-apnea pathway asks for six months on a different weight-loss drug first. Zepbound requires prescribing "by, or in consult with, a neurologist, pulmonologist, otolaryngologist, or other sleep medicine specialist," a diagnosis of "moderate to severe OSA defined as apnea-hypopnea index (AHI) > 15 determined by in-lab attended sleep study or polysomnography (PSG)," no type 2 diabetes, "a diagnosis of obesity (defined as BMI ≥ 30 kg/m2)," and a failed "6-month trial of continuous positive airway pressure (CPAP) along with the weight management program within the past year." It then adds that the member "must have documentation of participation in a comprehensive weight management program that includes behavioral modification, a reduced-calorie diet, increased physical activity, and pharmacotherapy for at least 6 months with semaglutide" — and that "If semaglutide is not tolerated, the pharmacotherapy requirement must be met with phentermine (if phentermine is unable to be used, bupropion, naltrexone, or topiramate may also be used to meet this requirement)." Renewal requires either an AHI drop of 20 percent or better, or "Weight loss from base line ≥ 10%."

North Dakota Medicaid, Pharmacy Coverage Policy Manual — Obstructive Sleep Apnea (OSA), effective July 2026 · source

The liver pathway puts the diabetes-labeled drugs first and Wegovy second. In the MASH section, Ozempic injection and brand-required Victoza are the preferred agents (both requiring prior authorization) while liraglutide, Rezdiffra and Wegovy injection are non-preferred. Approval requires prescribing "by, or in consult with, an endocrinologist, gastroenterologist or hepatologist" and "moderate to severe fibrosis (F2 or F3)" confirmed by biopsy, liver stiffness measurement, an enhanced liver fibrosis score, MRI-PDFF or magnetic resonance elastography. A member with alcohol use in the past five years must show "a phosphatidylethanol (PEth) level < 20 ng/mL" or two negative alcohol tests. And again there is a step: "If the member qualifies for Wegovy, a dose escalation to 2mg weekly of Ozempic injection (semaglutide) must be tolerated before Wegovy will be authorized."

North Dakota Medicaid, Pharmacy Coverage Policy Manual — Metabolic Dysfunction-Associated Steatohepatitis (MASH), effective July 2026 · source

North Dakota's general appeal window is 30 days, its managed-care window is 120 days, and the rule is precise about what each clock runs from and what counts as filing. The rule states that "an appeal or a request for a fair hearing must be filed within thirty days after the order or action with which the claimant is dissatisfied unless a different limitation is specified in state or federal law," and that "The date of the order or action on which the appeal or request for fair hearing is based is the date on which notice of the order or action was mailed to the claimant." A separate, much longer window applies where a plan has already ruled: a request "by an individual whose Medicaid benefits are administered through a managed care organization and has received notice of resolution that the managed care organization is upholding the adverse benefit determination must be filed no later than one hundred twenty days from the date of the notice of resolution." The same chapter defines the filing date for Medicaid appeals as "the date the request is received by the department or human service zone" — not the postmark date, which is the rule for other programs.

North Dakota Administrative Code, Chapter 75-01-03 (Appeals and Hearings), section 75-01-03-06, effective April 2018 · source