North Dakota Medicaid GLP-1 Coverage 2026: Pattern #44 — Middle-Ground “Covered for Everything Except Obesity” Architecture With FFS-Dominant Traditional Medicaid + BCBSND-Only Expansion MCO Overlay, Decisive 12-81 / 11-82 Legislative Rejection of HB 1451 / HB 1452, and Inverse Commercial-EHB-vs-Medicaid Posture

TL;DR — what North Dakota Medicaid covers and does not cover

The obesity-coverage anchor is verbatim on the ND Medicaid PDL 2026.4 (Effective April 1, 2026), page 84:

“Obesity. The following drugs are covered without prior authorization by submitting a corresponding diagnosis code for the indication: phentermine, bupropion, naltrexone, topiramate.”

The PDL bundles antipsychotic-induced weight gain coverage in the same section:

“Metformin is covered without prior authorization. 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.”

What ND Medicaid does NOT cover (standalone-obesity indication):

• Wegovy (semaglutide) for obesity
• Zepbound (tirzepatide) for obesity
• Saxenda (liraglutide) for obesity
• Branded fixed-combination Contrave (naltrexone/bupropion) — UNVERIFIED (components covered separately without PA)
• Branded fixed-combination Qsymia (phentermine/topiramate) — UNVERIFIED (components covered separately without PA)

What ND Medicaid DOES cover via FDA-label-restricted carve-outs (PA required unless otherwise noted):

What ND Medicaid covers for T2D (PDL 2026.4 page 69, GLP-1 Agonists section):

• Preferred (no PA required): Ozempic (semaglutide), Rybelsus (semaglutide tablets), Victoza (liraglutide — brand required)
• Non-preferred (PA required): Liraglutide (generic), Trulicity (dulaglutide)
• GIP/GLP-1 (PA required): Mounjaro (tirzepatide)

Notable T2D formulary quirk: brand Victoza is preferred while generic liraglutide is non-preferred — the inverse of the usual generics-preferred pharmacy-benefit pattern. This is driven by ND supplemental rebate agreements with Novo Nordisk, not by acquisition-cost economics.

Architectural distinctive features:

• Middle-ground “covered for everything except obesity” posture — ND is neither a pure-exclusion state (like Vermont Pattern #41 or Montana Pattern #46) nor a positive-coverage state (like Kansas Pattern #43 or Rhode Island Pattern #40). It covers the SELECT/MACE indication, the MASH indication, the OSA indication, the antipsychotic-induced weight gain indication, and the genetic-obesity indication — but not the standalone-obesity indication.
• Most restrictive Zepbound OSA carve-out in the series — required 6-month CPAP trial AND 6-month documented participation in a comprehensive weight-management program that includes pharmacotherapy with semaglutide (or phentermine / bupropion / naltrexone / topiramate fallback); 10% weight-loss reauthorization threshold; “most cost-effective tirzepatide product will be authorized” price-competition adjudication between Mounjaro and Zepbound.
• Off-label step-through to diabetes-indicated Ozempic 2 mg before SELECT-indicated Wegovy — pharmacy-policy utilization management quirk that requires patients to tolerate dose escalation to Ozempic 2 mg (or Rybelsus 14 mg for oral Wegovy MACE) BEFORE Wegovy is authorized for SELECT/MACE, even though Ozempic itself is not FDA-labeled for MACE-without-T2D.
• Decisive 12-81 / 11-82 legislative rejection (HB 1451 / HB 1452) — the most decisive legislative no-vote on Medicaid GLP-1 coverage in the 43-state series to date, on a single day (02/12/2025) in a single chamber.
• Inverse commercial-EHB-vs-Medicaid posture — ND added GLP-1 / GIP weight-loss coverage to the 2025 commercial EHB Benchmark Plan effective January 1, 2025; ND Medicaid does not cover GLP-1s for obesity. ND is one of the very few states in the series with this inversion.
• FFS-dominant + single-MCO expansion overlay architecture — FFS for traditional Medicaid (74% of all ND Medicaid spending is FFS) + BCBSND as sole expansion MCO under 1915(b) waiver — uniform pharmacy benefit via one PDL across both populations; functionally FFS-like but distinct from VT Pattern #41 (true 100% FFS, no MCO at all).
• Brand-Victoza-preferred / generic-liraglutide-non-preferred — rebate-driven formulary inversion; inverse of usual generics-preferred pharmacy-benefit pattern.
• Energy-economy fiscal posture — strongest oil/gas-tax-driven General Fund surplus of any state in the series (Legacy Fund approximately $10B). Despite the fiscal capacity, legislators rejected Medicaid GLP-1 expansion 12-81.
• Rural-majority enrollee base (54%) — highest rural share in the series; relevant to PA-friction friction (endocrinology, hepatology, sleep-medicine subspecialty access is thin outside Fargo, Bismarck, Grand Forks, Minot).
• Smallest state Medicaid in the series — 105,000 total enrollees.

Pharmacy benefit architecture:

• PBM / clinical: Acentra Health (ndmedicaid.acentra.com)
• Provider PA helpdesk: 1-866-773-0695
• Provider PA fax: 855-207-0250
• Pharmacy override line: 1-800-755-2604
• Pharmacy support email: medicaidpharmacy@nd.gov
• PA form lookup: nddruglookup.acentra.com (drug-specific PA forms) and nddruglookup.acentra.com/forms/General_PA_Form.pdf (General PA Form)
• PDL Version 2026.4: ndmedicaid.acentra.com/wp-content/uploads/sites/17/2026/03/PDL-2026.4.pdf (effective 04/01/2026)
• Delivery architecture: FFS for traditional Medicaid; BCBSND-administered 1915(b) managed care for Medicaid Expansion (~24,000 enrollees)

1. Federal authority and ND Medicaid policy framing

The federal Medicaid drug rebate statute at 42 U.S.C. § 1396r-8(d)(2)(A) grants states an optional authority to exclude “Agents when used for anorexia, weight loss, or weight gain” from coverage. ND has exercised this authority partially — not as a categorical exclusion across all weight-loss agents (the way Vermont Pattern #41 or Montana Pattern #46 have) but as a narrower exclusion that bites on the high-cost GLP-1 / GIP AOMs (Wegovy, Zepbound, Saxenda) while explicitly carving in the low-cost AOMs (phentermine, bupropion, naltrexone, topiramate as separate components).

The exclusion operates at the PDL-policy level only. There is no ND counterpart to Maine’s 10-144 C.M.R. ch. 101 Ch. II § 80.06(A) regulation specifically naming weight-loss drugs — the ND Pharmacy Coverage Policy Manual (the PDL) is the primary publicly accessible statement of the policy. The PDL is published by the NDDHHS Medical Services Division and is revised periodically (the most recent version 2026.4 effective April 1, 2026).

ND’s middle-ground posture is structurally distinct from the pure-exclusion states in the series. Where Vermont Pattern #41 anchors a categorical bundled exclusion (“Drugs used for weight loss, drugs used to promote fertility, and drugs used for cosmetic purposes or hair growth”) and Montana Pattern #46 carries a freestanding “weight-loss medications” Not Covered bucket in the DPHHS Prescription Drug Program Manual, ND’s PDL explicitly enumerates the four low-cost AOMs covered without PA AND the FDA-label-restricted carve-outs (SELECT/MACE, MASH, OSA, antipsychotic-induced weight gain, Imcivree). The result is a permissive-coverage policy for everything except the standalone-obesity indication of Wegovy / Zepbound / Saxenda.

ND adopted the ACA Medicaid expansion effective January 1, 2014. Medicaid Expansion (adults 19-64 at or below 138% FPL) is administered exclusively by BCBSND under a 1915(b) managed care waiver. The waiver-authority anchor for the BCBSND expansion contract is the 1915(b) freedom-of-choice waiver, which permits a state to require Medicaid beneficiaries to enroll in a specific managed care organization (here, the single-MCO BCBSND contract).

2. PDL anchor: ND Medicaid Pharmacy Coverage Policy Manual Version 2026.4

The ND Medicaid PDL Version 2026.4 effective April 1, 2026 is the binding policy document for ND Medicaid pharmacy coverage. The publisher’s line on page 1 reads verbatim:

“Pharmacy Coverage Policy Manual. Published By: Medical Services Division, North Dakota Department of Health and Human Services.”

The PDL is hosted on the Acentra Health Medicaid clinical-administration site (ndmedicaid.acentra.com/wp-content/uploads/sites/17/2026/03/PDL-2026.4.pdf). The PDL revision cadence is approximately quarterly; the current April 1, 2026 version is preceded by earlier 2026 versions (2026.3, 2026.2, 2026.1) and 2025 versions. The PDL is updated based on DUR / P&T Committee recommendations and CMS-required formulary updates.

Within the PDL, the GLP-1 / GIP coverage architecture spans multiple therapeutic-class sections:

• Page 39 — Cardiology Injectable Agents: Wegovy injection AND Wegovy tablets for SELECT/MACE; 12-month initial approval.
• Page 69 — GLP-1 Agonists: T2D coverage tier with Ozempic / Rybelsus / Victoza preferred (no PA), liraglutide generic / Trulicity non-preferred (PA), Mounjaro PA-required.
• Page 79 — Imcivree: Genetic-obesity coverage with confirmed POMC / PCSK1 / LEPR deficiency or Bardet-Biedl syndrome; 4-month initial (6-month for Bardet-Biedl).
• Page 84 — Obesity / Antipsychotic-Induced Weight Gain: phentermine / bupropion / naltrexone / topiramate covered without PA via obesity diagnosis code; Ozempic / Victoza covered without PA for antipsychotic-induced weight gain via T43.505A / T43.505D / T43.505S diagnosis codes.
• Page 131-132 — Hepatology / MASH: Wegovy injection non-preferred for MASH F2/F3 fibrosis with PA; Ozempic / Victoza brand-preferred for MASH; liraglutide generic / Rezdiffra non-preferred.
• Page 243 — Pulmonology / OSA: Zepbound for moderate-to-severe OSA with PA; 12-month initial; 10% weight-loss reauthorization threshold.

The architectural takeaway: ND covers GLP-1 / GIP agents under five distinct PDL sections for five distinct indications — cardiology (SELECT/MACE), endocrinology (T2D), hepatology (MASH), pulmonology (OSA), and the obesity section’s antipsychotic-induced weight gain pathway plus the Imcivree genetic-obesity pathway. The one indication NOT covered is the standalone-obesity indication of Wegovy / Zepbound / Saxenda (the indication that Kansas Pattern #43 covers under its AOM PA Form, Rhode Island Pattern #40 covers under its current MCO formularies, and Delaware Pattern #42 covers under its DMAP PDL).

3. Wegovy SELECT/MACE carve-out (Cardiology Injectable Agents PDL section, p. 39)

Per the ND Medicaid PDL 2026.4 Cardiology Injectable Agents section (page 39), the Wegovy SELECT/MACE carve-out criteria verbatim are:

“Initial Criteria – Approval Duration: 12 months

The member is between ages of ≥ 55 and < 75.

The member does not have diabetes, as evidenced by A1c within normal range without diabetes medication.

The member has an initial BMI of ≥ 27 kg/m² and < 35 kg/m²

The member has one of the following: Prior myocardial infarction (MI); Prior stroke and peripheral arterial disease (PAD)...

The member is concurrently taking lipid-lowering and antiplatelet therapy

If the member is a current tobacco user, the member must have received tobacco cessation counseling in the past year

If the member qualifies for Wegovy injection, a dose escalation to 2mg of Ozempic (semaglutide) must be tolerated before Wegovy will be authorized (2.4mg is the only strength indicated for reduction of MACE)

If the member qualifies for Wegovy tablets, a dose escalation to 14mg of Rybelsus (semaglutide) must be tolerated before Wegovy will be authorized.”

Reauthorization failure definition verbatim:

“Failure is defined as one of the following: The member is unable to achieve weight loss of at least 5% from baseline; The member is unable to achieve reduction of BMI of at least 5% from baseline; The member has experienced a cardiovascular event following a 5% weight loss or 5% reduction of BMI since starting medication.”

3.1 Age 55-74 window (SELECT trial population)

ND’s age window of ≥ 55 and < 75 mirrors the SELECT trial entry criterion. This is narrower than most state Wegovy MACE carve-outs (which typically gate on the FDA label only, not the SELECT age window). A ND patient aged 54 with prior MI would fail the ND criteria; a patient aged 75 would also fail. The age window is the most restrictive in the cardiology PDL section of the series.

3.2 BMI 27-34.9 window (no severe-obesity ceiling explicit, but operative)

ND’s BMI window of ≥ 27 and < 35 kg/m² is unusual in including a ceiling of 35. A patient with BMI 35.0 or higher would technically fail the SELECT/MACE criteria as written. This may route severe-obesity SELECT/MACE patients to alternative pathways (e.g., the standalone-obesity indication, which ND does not cover; or the MASH indication if F2/F3 fibrosis is also documented). The ceiling is the most restrictive in the series — most states gate only on BMI floor, not ceiling.

3.3 No-diabetes requirement (A1c normal off Rx)

ND’s no-diabetes requirement is verbatim “the member does not have diabetes, as evidenced by A1c within normal range without diabetes medication.” This excludes patients on ANY diabetes medication (including metformin used for prediabetes or PCOS) — the patient must be off all diabetes medications AND demonstrate normal A1c (typically < 5.7%). A patient with T2D in remission on metformin maintenance would fail the criteria; the prescriber would need to discontinue metformin and demonstrate A1c < 5.7% off medication before Wegovy SELECT/MACE could be authorized.

3.4 Off-label Ozempic 2 mg step-through (Pattern #44 distinctive quirk)

ND’s pharmacy-policy utilization management quirk requires the patient to tolerate dose escalation to Ozempic 2 mg BEFORE Wegovy is authorized for SELECT/MACE — even though Ozempic itself is not FDA-labeled for MACE-without-T2D. The PDL verbatim acknowledges this: “2.4mg is the only strength indicated for reduction of MACE” (referring to Wegovy 2.4 mg, which is the SELECT trial dose). The off-label-step-through-to-Ozempic-2-mg before SELECT-indicated Wegovy is a pharmacy-policy choice that prioritizes the rebate-favored Ozempic over the SELECT-indicated Wegovy — functionally a step-therapy that uses an off-label dose to satisfy the utilization-management requirement.

For oral Wegovy MACE (oral semaglutide for cardiovascular risk reduction), the parallel step-through is to Rybelsus 14 mg (the highest oral semaglutide dose). Patient must tolerate Rybelsus 14 mg before oral Wegovy MACE will be authorized.

Practical implication: a SELECT-eligible patient (BMI 27-34.9, age 55-74, prior MI, no T2D, on lipid + antiplatelet) cannot start Wegovy 2.4 mg directly. The prescriber must first titrate the patient on Ozempic to the 2 mg dose (the highest T2D Ozempic dose), document tolerance, and only then submit a PA for the Wegovy 2.4 mg SELECT/MACE indication. This adds approximately 12-16 weeks of titration delay before SELECT-indicated Wegovy can be initiated.

3.5 Concurrent lipid-lowering + antiplatelet therapy required

ND requires concurrent statin (or other lipid-lowering therapy) AND antiplatelet therapy (typically aspirin or clopidogrel, depending on the patient’s prior MI / stroke / PAD history). A patient not on both classes at the time of PA submission would fail the criteria. Documentation: the PA submission should include the current medication list with both classes verified.

3.6 Tobacco-cessation counseling within past year (if current user)

If the member is a current tobacco user, tobacco-cessation counseling within the past 12 months must be documented. ND is one of the few states in the series with an explicit tobacco-cessation-counseling prerequisite for the cardiology carve-out. Documentation: a counseling note from the primary care physician, cardiologist, or smoking cessation specialist; a quit-line referral; or pharmacotherapy initiation (nicotine replacement, varenicline, bupropion).

3.7 12-month initial approval and 5% weight-loss / BMI-loss reauthorization

Initial approval is 12 months (longer than the 6-month approvals in Vermont Pattern #41 or Maine Pattern #39). Reauthorization fails if the member is unable to achieve 5% weight loss OR 5% BMI loss from baseline, OR experiences a cardiovascular event following a 5% weight loss / BMI loss since starting medication. The weight-loss-tied reauthorization is operationally similar to the Zepbound OSA reauthorization milestone but applied to the SELECT/MACE indication.

4. Wegovy MASH carve-out (Hepatology PDL section, p. 131-132)

Per the ND Medicaid PDL 2026.4 Hepatology section (pages 131-132), the MASH coverage tier verbatim is:

“MASH — PREFERRED AGENTS (PA REQUIRED): OZEMPIC (semaglutide), VICTOZA (liraglutide) – Brand Preferred.

NON-PREFERRED AGENTS (PA REQUIRED): liraglutide, REZDIFFRA (resmetirom), WEGOVY (semaglutide) injection.”

Initial criteria include: prescribed by or in consultation with an endocrinologist, gastroenterologist, or hepatologist; F2 or F3 fibrosis documented by biopsy, vibration-controlled transient elastography (VCTE / FibroScan), Enhanced Liver Fibrosis (ELF) score, MR-PDFF (magnetic resonance proton density fat fraction), or MR elastography (MRE); and if the member has a history of alcohol use within the past 5 years, alcohol abstinence documented with phosphatidylethanol (PEth) less than 20 ng/mL.

For Wegovy specifically (non-preferred for MASH), the additional step-through criterion verbatim:

“If the member qualifies for Wegovy, a dose escalation to 2mg weekly of Ozempic (semaglutide) must be tolerated before Wegovy will be authorized.”

4.1 ND’s MASH PDL pre-dates the FDA August 2025 label expansion

ND’s MASH PDL pre-dates the FDA’s August 2025 MASH-specific semaglutide label expansion. The PDL was already treating Wegovy MASH coverage as a clinical decision rather than waiting on FDA approval. This is operationally permissive (patients with documented F2/F3 fibrosis had access before the FDA label expansion) but procedurally unusual (most state Medicaid programs wait for the FDA label before adding indication-specific carve-outs).

4.2 Five-modality F2/F3 fibrosis confirmation pathway

ND accepts F2/F3 fibrosis confirmation by ANY ONE of five modalities:

• Biopsy — the gold standard but invasive; reserved for diagnostically uncertain cases.
• VCTE / FibroScan — the most accessible non-invasive test; liver stiffness measurement 8–14 kPa typically corresponds to F2–F3 fibrosis.
• ELF score — serologic test combining hyaluronic acid, procollagen III amino-terminal peptide, and tissue inhibitor of metalloproteinase-1; cutoff > 9.8 typically corresponds to advanced fibrosis.
• MR-PDFF — quantifies hepatic steatosis but does NOT directly measure fibrosis; typically used in combination with MRE.
• MRE — MR elastography; the most accurate non-invasive fibrosis test; 2.99–4.7 kPa corresponds to F2–F3.

ND’s five-modality acceptance is broader than Vermont Pattern #41’s dual-modality requirement (two non-invasive tests OR biopsy with NAFLD ≥ 4) — meaning ND patients can qualify with a single non-invasive test of any one modality, as long as the result is consistent with F2/F3 fibrosis. This is operationally permissive.

4.3 PEth < 20 ng/mL alcohol-abstinence biomarker

If the member has a history of alcohol use within the past 5 years, alcohol abstinence must be documented with phosphatidylethanol (PEth) less than 20 ng/mL. PEth is a phospholipid biomarker formed in red blood cells only in the presence of ethanol; it has a 2-3 week detection window and is more rigorous than patient self-report or the AUDIT-C alcohol-use screening questionnaire. The PEth < 20 ng/mL cutoff corresponds to abstinence or very light drinking (about 1 drink per week).

ND’s PEth biomarker requirement is more rigorous than most state MASH carve-outs (which typically rely on AUDIT-C screening or patient self-report). The 5-year look-back is unusual — most state carve-outs use 12-24 months. Practical implication: patients with any history of alcohol use within the past 5 years must demonstrate sustained abstinence via PEth testing before Wegovy MASH can be authorized.

4.4 Endocrinology / GI / hepatology consult requirement

The prescription must be from an endocrinologist, gastroenterologist, or hepatologist, or be prescribed in consultation with one. Primary care physicians cannot directly prescribe under this carve-out without subspecialty input. The endocrinology pathway is unusual in MASH PA criteria — most states limit prescribing to GI / hepatology — and reflects the metabolic-syndrome framing of MASH.

4.5 Ozempic 2 mg step-through (parallel to SELECT/MACE)

ND requires the same off-label Ozempic 2 mg step-through for Wegovy MASH as for Wegovy SELECT/MACE. The patient must tolerate dose escalation to Ozempic 2 mg weekly before Wegovy will be authorized for the MASH indication. This is structurally parallel to the SELECT/MACE step-through and reflects the rebate-favored positioning of Ozempic over Wegovy.

Notable: Ozempic is the preferred MASH agent (no step-through required for Ozempic) while Wegovy is non-preferred. A patient with F2/F3 MASH can start on Ozempic directly under the MASH preferred-agent pathway; the Wegovy step-through is only required if the prescriber specifically wants to use Wegovy rather than Ozempic.

5. Zepbound OSA carve-out (Pulmonology PDL section, p. 243) — the most restrictive in the series

Per the ND Medicaid PDL 2026.4 Pulmonology section (page 243), the Zepbound OSA carve-out is the MOST restrictive in the 43-state series tracked to date. Criteria verbatim:

“Obstructive Sleep Apnea (OSA) — PA REQUIRED: ZEPBOUND (tirzepatide)

Initial Criteria – Approval Duration: 12 months

The requested medication must be prescribed by, or in consult with, a neurologist, pulmonologist, otolaryngologist, or other sleep medicine specialist

The member must have a diagnosis of moderate to severe OSA defined as apnea-hypopnea index (AHI) > 15 determined by in-lab attended sleep study or polysomnography (PSG)

The member does not have diabetes type II

The member must have a diagnosis of obesity (defined as BMI ≥ 30 kg/m²)

The member must have failed a 6-month trial of continuous positive airway pressure (CPAP) along with the weight management program within the past year, as evidenced by apnea-hypopnea index (AHI) > 15.

Zepbound Only:

The member must meet FDA-approved label for use (e.g., use outside of studied population will be considered investigational)

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.

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)

If the member qualifies for tirzepatide, the most cost-effective tirzepatide product will be authorized

Renewal Criteria – Approval Duration: 12 months

Decrease in AHI determined by PSG ≥ 20%, or change in OSA severity status to Remission or Mild Non-Symptomatic OSA (defined as AHI < 5 or AHI 5-14 AND Epworth Sleepiness Scale (ESS) ≤ 10)

Weight loss from baseline ≥ 10%.”

5.1 In-lab attended PSG required (no home sleep study)

ND requires the AHI > 15 diagnosis to be determined by an in-lab attended sleep study or polysomnography (PSG) — not a home sleep apnea test (HSAT). This is more restrictive than several state OSA carve-outs that accept HSAT (e.g., Vermont Pattern #41 does not specify in-lab vs. home; Maine Pattern #39 does not specify). The in-lab PSG requirement adds friction for rural ND patients who must travel to Fargo, Bismarck, Grand Forks, or Minot for an in-lab sleep study.

5.2 6-month CPAP trial AND 6-month comprehensive weight-management program with semaglutide

ND’s OSA carve-out requires a 6-month documented CPAP failure (AHI > 15 despite CPAP) AND a 6-month documented participation in a comprehensive weight-management program that includes pharmacotherapy with semaglutide. If semaglutide is not tolerated, the pharmacotherapy requirement can be met with phentermine; if phentermine cannot be used, bupropion, naltrexone, or topiramate can substitute.

This is the most restrictive Zepbound OSA carve-out in the series. The cumulative time-in-process is substantial: 6 months of CPAP titration + 6 months of semaglutide-or-equivalent pharmacotherapy. A newly diagnosed OSA patient with BMI 31 cannot start Zepbound for OSA in ND for at least 12 months after diagnosis — even if they qualify on all other criteria.

By comparison:

• Vermont Pattern #41: Zepbound OSA requires CPAP prescribed (not failed); no semaglutide pre-trial required.
• Maine Pattern #39: Zepbound OSA requires CPAP “ineffective or intolerant for 90 days”; no semaglutide pre-trial.
• Utah Pattern #37: Zepbound OSA requires 70% PAP adherence followed by failure; no semaglutide pre-trial.
• West Virginia Pattern #36: Zepbound OSA requires CPAP counseling; no semaglutide pre-trial.
• North Dakota Pattern #44: 6-month CPAP failure AND 6-month semaglutide-or-equivalent comprehensive weight-management program.

5.3 BMI ≥ 30 floor (SURMOUNT-OSA trial population)

ND’s BMI threshold of ≥ 30 kg/m² matches the SURMOUNT-OSA trial entry criterion and is structurally consistent with the FDA label for Zepbound OSA.

5.4 T2D exclusion routes T2D-with-OSA patients elsewhere

The Zepbound OSA carve-out excludes patients with T2D. T2D-with-OSA patients are routed instead through the T2D pharmacy pathway — Mounjaro (tirzepatide) is PA-required for T2D under the GLP-1 Agonists section. A T2D patient with OSA cannot stack the OSA carve-out with the T2D pathway; the T2D indication takes precedence and Mounjaro (not Zepbound) is the operative product.

5.5 “Most cost-effective tirzepatide product will be authorized” (Mounjaro vs. Zepbound price competition)

ND’s Zepbound OSA carve-out includes the unique clause verbatim: “If the member qualifies for tirzepatide, the most cost-effective tirzepatide product will be authorized.” This means Mounjaro (T2D label) and Zepbound (obesity / OSA label) compete on price at the point of adjudication — even though Mounjaro is not FDA-labeled for OSA. ND Medicaid may authorize Mounjaro instead of Zepbound for an OSA-qualifying patient if Mounjaro is more cost-effective after net-of-rebates pricing. This is a pharmacy-policy choice that prioritizes rebate-net price over FDA-labeled indication.

Practical implication: the prescriber should be prepared for the PA approval to be for Mounjaro rather than Zepbound, even if the prescription was written for Zepbound. The therapeutic-substitution between tirzepatide products may require additional patient counseling (different packaging, different brand recognition, but identical active ingredient and dosing).

5.6 10% weight-loss reauthorization threshold (highest in series)

Reauthorization at 12 months requires 10% weight loss from baseline — the highest reauthorization weight-loss threshold in the series. Vermont Pattern #41 and Maine Pattern #39 use 5% (mirroring SURMOUNT-OSA endpoint); ND uses 10% (twice the SURMOUNT-OSA endpoint). The higher threshold combined with the AHI ≥ 20% decrease OR remission-or-mild-non-symptomatic OSA criterion makes the renewal gate substantially higher than other OSA carve-outs in the series.

The dual reauthorization requirement (AHI decrease OR OSA-severity-status change AND 10% weight loss) means a patient who achieves the AHI / OSA-severity criterion but not the 10% weight loss would still fail reauthorization — OR is the AHI criterion alternative, but the weight-loss criterion is a separate AND clause.

6. Ozempic / Victoza for antipsychotic-induced weight gain (no PA required)

Per the ND Medicaid PDL 2026.4 Obesity section (page 84), Ozempic and Victoza (brand) are covered without PA for antipsychotic-induced weight gain via three ICD-10 diagnosis codes:

• T43.505A — Adverse effect of unspecified antipsychotics and neuroleptics, initial encounter
• T43.505D — Adverse effect of unspecified antipsychotics and neuroleptics, subsequent encounter
• T43.505S — Adverse effect of unspecified antipsychotics and neuroleptics, sequela

Metformin is also covered without PA for antipsychotic-induced weight gain (same diagnosis-code bypass).

6.1 Why this matters in serious mental illness populations

Antipsychotic-induced weight gain is a major iatrogenic harm in serious mental illness populations (schizophrenia, schizoaffective disorder, bipolar disorder). Second-generation antipsychotics (olanzapine, clozapine, quetiapine, risperidone) frequently cause 10-30 pound weight gain in the first 12 months of treatment, with associated metabolic syndrome, T2D risk, and cardiovascular risk. The American Psychiatric Association practice guidelines recommend metformin as first-line for antipsychotic-induced weight gain; GLP-1 receptor agonists are emerging as second-line evidence-based options.

ND’s bypass-PA-with-diagnosis-code structure is unusual in the series — most state Medicaid programs route Ozempic / Victoza for antipsychotic-induced weight gain through standard PA review (with the same PA criteria as T2D-indicated use). ND’s decision to bypass PA reflects: (1) the clear iatrogenic causation (the patient is on an antipsychotic causing the weight gain); (2) the relatively narrow population (serious mental illness with documented antipsychotic-induced weight gain); (3) the public-health framing of preventing antipsychotic-induced metabolic syndrome in a vulnerable population.

6.2 Practical PA submission strategy

For a Medicaid beneficiary on an antipsychotic who has documented weight gain, the prescribing psychiatrist or primary care physician should ensure the pharmacy claim is submitted with one of the three T43.505 diagnosis codes attached. The pharmacy claim should adjudicate without PA at the point of sale. If the claim rejects for PA-required, the pharmacy or prescriber should contact Acentra Health at 1-866-773-0695 to verify the diagnosis code attachment.

Notable: only Ozempic and Victoza (brand) are covered without PA for antipsychotic-induced weight gain. Wegovy, Zepbound, Saxenda, Mounjaro, Trulicity, and Rybelsus are NOT covered under this no-PA pathway. The two preferred agents reflect the rebate-favored brand-required Victoza and Ozempic on the T2D PDL.

7. Imcivree (setmelanotide) for genetic obesity disorders (PDL p. 79)

Per the ND Medicaid PDL 2026.4 page 79, Imcivree (setmelanotide) is covered with PA for:

• Confirmed POMC (proopiomelanocortin) deficiency
• Confirmed PCSK1 (proprotein convertase subtilisin/kexin type 1) deficiency
• Confirmed LEPR (leptin receptor) deficiency
• Bardet-Biedl syndrome

BMI thresholds:

• Adults: BMI > 30 kg/m²
• Pediatric: BMI > 95th percentile for age and sex per CDC growth charts

Approval durations:

• POMC / PCSK1 / LEPR deficiency: 4 months initial
• Bardet-Biedl syndrome: 6 months initial

The shorter Imcivree initial approval (4-6 months vs. 12 months for Wegovy MACE / MASH and Zepbound OSA) reflects the high acquisition cost of setmelanotide and the requirement for early clinical-response assessment to justify continuation. For Bardet-Biedl syndrome specifically, the diagnosis requires three or more major clinical features (e.g., retinitis pigmentosa, polydactyly, central obesity, intellectual disability, hypogonadism, renal abnormalities).

8. T2D-indicated GLP-1 PDL coverage (page 69)

Per the ND Medicaid PDL 2026.4 GLP-1 Agonists section (page 69), the T2D coverage tier verbatim:

“GLP-1 Agonists — PREFERRED AGENTS (NO PA REQUIRED): OZEMPIC (semaglutide), RYBELSUS (semaglutide), VICTOZA (liraglutide) – Brand Required.

NON-PREFERRED AGENTS (PA REQUIRED): liraglutide [generic], TRULICITY (dulaglutide).”

Mounjaro (tirzepatide) is covered as a GIP/GLP-1 with PA required.

T2D PA criteria (12-month initial approval for non-preferred agents and Mounjaro):

• A1c at or below 7% or time-in-range above 70% glycemic goals
• 90-day trial of triple combination therapy (Ozempic + metformin + SGLT-2 inhibitor; or SGLT-2 inhibitor + DPP-4 inhibitor + metformin; or Ozempic + insulin)
• Endocrinology or diabetes-specialist prescribing or consultation OR diabetes education from a specialist
• GI-side-effect bypass pathway: 2-month diet / antiemetic / dose-reduction trials documented before non-preferred PA

8.1 Brand-Victoza-preferred / generic-liraglutide-non-preferred quirk

ND’s formulary places brand Victoza on the preferred tier while generic liraglutide is non-preferred. This is the inverse of the usual generics-preferred pharmacy-benefit pattern and reflects the strength of Novo Nordisk’s supplemental rebate arrangement with the ND Medicaid Pharmacy Coverage Policy program. The brand-required designation means a prescriber cannot substitute generic liraglutide for brand Victoza without an explicit non-preferred PA.

Practical implication for a prescriber: a T2D patient on liraglutide should be prescribed brand Victoza (preferred, no PA) rather than generic liraglutide (non-preferred, PA required). The brand-vs-generic price differential is offset by the net-of-rebates pricing under the Novo Nordisk rebate agreement.

8.2 Mounjaro PA via GIP/GLP-1 pathway

Mounjaro is covered for T2D with PA. The PA criteria include the standard T2D PA criteria (A1c at or below 7% / TIR above 70%, 90-day triple-combination step-therapy, endocrinology / diabetes-specialist consultation, GI-side-effect bypass pathway). Mounjaro may also be authorized for OSA via the “most cost-effective tirzepatide product” clause in the Zepbound OSA carve-out (see Section 5.5).

9. PA submission process end-to-end

ND Medicaid PA submissions are handled by Acentra Health on behalf of the NDDHHS Medical Services Division. The general PA pathway:

9.1 Forms

• General Prior Authorization Form — URL: nddruglookup.acentra.com — General PA Form
• Drug-specific PA forms lookup — URL: nddruglookup.acentra.com

9.2 Submission contacts

• PA fax: 855-207-0250 (Acentra Health / Health Information Designs PA intake)
• Phone (Acentra provider relations): 1-866-773-0695
• Pharmacy override line: 1-800-755-2604
• Pharmacy support email: medicaidpharmacy@nd.gov

9.3 Step-by-step

1. Confirm indication and select the correct form. Wegovy SELECT/MACE = drug-specific Wegovy PA form (via lookup). Wegovy MASH = drug-specific Wegovy MASH PA form. Zepbound OSA = drug-specific Zepbound PA form. T2D non-preferred (liraglutide / Trulicity) and Mounjaro = General PA Form with T2D criteria documentation. Antipsychotic-induced weight gain (Ozempic / Victoza) = no PA required, just attach diagnosis code T43.505A / T43.505D / T43.505S to the pharmacy claim. Imcivree = drug-specific Imcivree PA form.
2. Document the patient's diagnosis with ICD-10 code. Wegovy SELECT/MACE: I63.x (cerebral infarction), I21.x (acute MI history), I70.21x (atherosclerosis of native arteries of extremities with intermittent claudication). Wegovy MASH: K76.81 (NASH / MASH). Zepbound OSA: G47.33 (OSA). Imcivree POMC / PCSK1 / LEPR: E66.811 (obesity with specified genetic deficiency) or E66.819 (obesity due to other endocrine and genetic causes). Imcivree Bardet-Biedl: Q87.89.
3. Document BMI to one decimal place. Wegovy MACE: BMI 27.0-34.9 (note ceiling of < 35). Wegovy MASH: no explicit BMI floor in PDL but F2/F3 fibrosis required. Zepbound OSA: BMI ≥ 30. Imcivree: BMI > 30 adult or > 95th percentile pediatric.
4. Attach indication-specific clinical evidence. Wegovy MACE: A1c documenting no diabetes off Rx + cardiology consult note + ECG / cath / imaging showing prior MI / stroke / PAD + current lipid + antiplatelet medication list + tobacco-cessation counseling note if current tobacco user + documentation of Ozempic 2 mg (or Rybelsus 14 mg for oral) step-through tolerance. Wegovy MASH: F2/F3 fibrosis documentation (biopsy, VCTE, ELF, MR-PDFF, or MRE) + endocrinology / GI / hepatology consult note + PEth less than 20 ng/mL if 5-year alcohol history + Ozempic 2 mg step-through tolerance. Zepbound OSA: in-lab attended PSG report with AHI greater than 15 + sleep-medicine specialist consult + 6-month CPAP failure documentation (AHI greater than 15 despite CPAP) + 6-month documented participation in comprehensive weight-management program with semaglutide or fallback pharmacotherapy + exclusion documentation for T2D.
5. Fax to Acentra Health at 855-207-0250 with a fax cover sheet identifying the patient, the drug, the indication, and the prescriber.
6. For status checks, call Acentra Health provider relations at 1-866-773-0695.
7. For time-sensitive scenarios, use the pharmacy override line at 1-800-755-2604.
8. Receive approval / denial decision. Adjudication turnaround is UNVERIFIED in publicly available NDDHHS / Acentra documentation; federal floor is 24 hours standard / same-day expedited per 42 CFR section 440.230.
9. At 12 months, submit reauthorization request. Wegovy MACE: 5% weight-loss or BMI-loss documentation, OR documentation of no cardiovascular event after a 5% loss. Wegovy MASH: stable or improved fibrosis on serial non-invasive testing. Zepbound OSA: at least 20% AHI decrease OR remission / mild non-symptomatic OSA on follow-up PSG AND at least 10% weight loss from baseline.

10. Appeals pathway: SFN 162 fair hearing within 30 days

10.1 SFN 162 Request for Hearing

ND Medicaid uses a single-step fair-hearing appeals pathway. The appeals form is SFN 162 — Request for Hearing; the explanatory document is DN 263 — Rights to a Hearing.

• Filing deadline: within 30 days of the notice mailing date (the date stamped on the denial notice mailed to you)
• Submission method verbatim: “An appeal can be filed verbally over the phone, or in written format by email, fax or mail.”
• Mailing: Appeals Supervisor, Legal Division, 600 E Boulevard Ave., Dept. 325, Bismarck, ND 58505-0250
• Phone: (701) 328-2311 or toll-free (800) 472-2622
• TTY: 711
• Email: dhslau@nd.gov

10.2 NDDHHS hearing officer (not external OAH)

The hearing is heard by an NDDHHS hearing officer (not by an external Office of Administrative Hearings, as in Kansas Pattern #43 or Maine Pattern #39). The hearing officer is an NDDHHS employee operating in an adjudicative capacity. The hearing officer’s decision is binding for the agency.

10.3 Further appeal to ND District Court

If the NDDHHS hearing officer affirms the denial, the further appeal is to the North Dakota District Court under N.D.C.C. ch. 28-32 (Administrative Agencies Practice Act). The District Court reviews the administrative record under a substantial-evidence standard of review.

10.4 Expedited fair-hearing timeline — UNVERIFIED

The ND-specific expedited fair-hearing timeline is UNVERIFIED in publicly available DN 263 / NDDHHS appeals documentation. The federal floor under 42 CFR section 431.224 is 3 working days for an expedited fair hearing when the standard timeframe could jeopardize life, health, or function.

10.5 Practical denial-recovery strategy

1. First, call Acentra Health provider relations at 1-866-773-0695. Many ND Medicaid AOM denials are documentation deficiencies recoverable via re-submission of the same PA form with additional clinical evidence. Common deficiency patterns: missing PEth alcohol-abstinence marker for MASH; missing 6-month CPAP + 6-month semaglutide trial documentation for OSA; missing tobacco-cessation counseling note for SELECT/MACE; missing Ozempic 2 mg step-through tolerance documentation; missing in-lab attended PSG (only home sleep study submitted).
2. If the denial is substantive (criteria-based), re-submit the PA form with stronger evidence. For SELECT/MACE denials based on insufficient CVD documentation, add a cardiology consult note + objective imaging + lipid + antiplatelet medication list verification. For Zepbound OSA denials based on insufficient CPAP / semaglutide trial documentation, add explicit month-by-month CPAP adherence reports (CPAP machine data) + semaglutide prescription history with adherence documentation.
3. If re-submission fails, file the SFN 162 Request for Hearing within 30 days of the denial notice. Request aid-paid-pending in the SFN 162 submission (coverage continues during the hearing if requested). For urgent scenarios, request expedited review.
4. If the NDDHHS hearing officer affirms the denial, file an appeal to ND District Court under N.D.C.C. ch. 28-32.
5. Contact ND Legal Aid or other legal-aid organizations for representation. The DN 263 Rights to a Hearing explainer references the availability of free legal representation.

11. Recent legislative activity: HB 1451 / HB 1452 (2025) — decisive 12-81 / 11-82 rejection

The 69th ND Legislative Assembly (2025-2026 biennium) saw a coordinated obesity-coverage push that FAILED decisively on a single day in the House.

11.1 HB 1451 — Medicaid AOM coverage

HB 1451 was titled verbatim:

“A BILL for an Act to create and enact a new section to chapter 50-24.1 of the North Dakota Century Code, relating to medical assistance prescription drug benefits for antiobesity medication.”

Sponsors: Rep. Jon Nelson (R), Rep. Alisa Mitskog (D), and Rep. O’Brien. The bill would have required ND Medicaid AND the BCBSND-administered Medicaid Expansion population to cover FDA-approved GLP-1 medications for the obesity treatment indication.

Final disposition: HB 1451 FAILED on second reading in the ND House on 02/12/2025 by a vote of 12 yeas to 81 nays.

11.2 HB 1452 — NDPERS state-employee plan AOM coverage

Companion bill HB 1452 was titled: “Establish new standards regarding health insurance coverage of antiobesity medication, require a legislative report” — applying to the NDPERS state employee health plan. Sponsors: Rep. Jon Nelson and Rep. Alisa Mitskog.

Final disposition: HB 1452 FAILED on second reading the same day (02/12/2025), 11 yeas to 82 nays.

11.3 The 70-vote margin is the most decisive legislative no-vote in the series

The combined 70-vote margin against on both bills on a single day in a single chamber is the most decisive legislative no-vote on Medicaid GLP-1 coverage tracked in the 43-state series to date. By comparison:

• Vermont H.765 / S.164 (2024): stalled in committee without floor vote
• Maine LD 480 (2025): Ought-Not-To-Pass March 20, 2025 (committee vote, not floor vote)
• Nebraska LB907 (2024): Indefinitely Postponed
• Montana SB 417 (Sen. Ellie Boldman AOM mandate, 2025): died 11-1 in committee March 1, 2025 (committee vote)
• Kansas HAWK Act HB 2375 (2025-2026): died in committee
• North Dakota HB 1451 / HB 1452 (2025): FAILED 12-81 / 11-82 on House floor — the only state in this comparison group with a recorded full-chamber floor vote, and the most decisive margin against

11.4 Energy-economy fiscal context

ND has the strongest oil/gas-tax-driven General Fund surplus of any state in the series — the ND Legacy Fund stands at approximately $10 billion as of 2026. The state has the fiscal capacity to add Medicaid AOM coverage without raising taxes or cutting other programs. The decisive 70-vote rejection of HB 1451 / HB 1452 is therefore not a fiscal-pressure rejection (as Vermont’s H.765 / S.164 stall under DVHA’s $75M annual estimate or Nebraska’s LB907 stall under the $42.4M fiscal note) — it is a policy-philosophy rejection.

The rejection reflects ND legislators’ framing of GLP-1 obesity coverage as a discretionary benefit that the Medicaid program should not bear, rather than a cost-pressure question. The pattern is distinct from peer-state rejections that anchored in fiscal-note magnitudes.

12. The inverse posture: ND commercial EHB covers GLP-1s for morbid obesity (1/1/2025)

North Dakota added GLP-1 / GIP weight-loss drug coverage to the commercial 2025 Essential Health Benefits (EHB) Benchmark Plan effective January 1, 2025 — applicable to the commercial ACA-marketplace individual and small-group market in ND. The ND Insurance Department 2025 Benchmark FAQ states verbatim:

“Weight loss drugs: Coverage for the use of glucagon-like peptide-1 (GLP1) and gastric inhibitory polypeptide (GIP) drugs as therapy for the prevention of diabetes and treatment of insulin resistance, metabolic syndrome, or morbid obesity.”

This creates an inverse-of-typical “ACA covers, Medicaid doesn’t” structure in ND — the commercial individual / small-group market covers GLP-1s for morbid obesity while the Medicaid program does not. Most states in the series have the opposite structure: Medicaid is the most generous payer because of the federal drug rebate framework at 42 U.S.C. section 1396r-8 that lowers net-of-rebates Medicaid pricing below commercial pricing.

12.1 Practical implications

A North Dakotan with morbid obesity who increases earnings above 138% FPL and transitions from Medicaid Expansion (BCBSND-administered) to commercial ACA-marketplace coverage GAINS access to GLP-1 obesity coverage. Conversely, a ND commercial-market patient who loses commercial coverage and falls onto Medicaid Expansion (BCBSND-administered) LOSES GLP-1 obesity access.

This is the inverse of the usual Medicaid-is-the-most-generous-payer structure and creates a unique policy whiplash for ND Medicaid Expansion beneficiaries near the 138% FPL income threshold who experience income variability.

12.2 2026 EHB Benchmark — UNVERIFIED

The ND 2026 EHB Benchmark Plan is UNVERIFIED in publicly available ND Insurance Department documentation. The 2025 inclusion is documented; the 2026 plan may have continued, expanded, or restricted the GLP-1 / GIP coverage. ND consumers should verify their specific commercial plan’s 2026 formulary for GLP-1 / GIP coverage at the individual policy level.

13. UNVERIFIED items — flagged honestly

Per Weight Loss Rankings’ YMYL 125% accuracy standard, the following items are flagged as UNVERIFIED rather than fabricated. These are gaps in the publicly available ND Medicaid primary sources that readers should verify independently:

1. ND-specific PA adjudication turnaround time. The PDL 2026.4 does not specify a standard or expedited PA adjudication SLA. Federal floor is 24 hours standard / same-day expedited per 42 CFR section 440.230.
2. Expedited fair-hearing timeline under DN 263. The standard SFN 162 fair-hearing process is documented but the expedited timeline is not explicitly stated. Federal floor is 3 working days per 42 CFR section 431.224.
3. Contrave (naltrexone/bupropion) and Qsymia (phentermine/topiramate) branded combo status. The PDL covers the components separately (bupropion + naltrexone for Contrave components; phentermine + topiramate for Qsymia components) without PA, but does not explicitly address whether the branded fixed-combination products are covered.
4. Adolescent Wegovy coverage pathway for standalone obesity. The PDL does not contain an explicit adolescent Wegovy obesity carve-out. Default position is that pediatric obesity-indicated Wegovy is excluded. EPSDT (42 U.S.C. section 1396d(r)) provides a federal floor for medical necessity in members under 21.
5. Specific ICD-10 codes for each Wegovy / Zepbound PA pathway. The PDL references the clinical-indication categories but does not specify the exact ICD-10 codes required on the PA submission. Standard codes (I63.x, I21.x, I70.21x for SELECT/MACE; K76.81 for MASH; G47.33 for OSA) are clinically appropriate but ND-specific code preferences are UNVERIFIED.
6. Whether BCBSND Medicaid Expansion uses the ND Medicaid PDL or maintains an internal formulary. Default assumption is parity with the state PDL, but UNVERIFIED whether BCBSND has discretion to deviate on AOM coverage specifically.
7. ND 2026 EHB Benchmark Plan GLP-1 / GIP coverage continuation status. The 2025 inclusion is documented; the 2026 plan continuation is UNVERIFIED.

If you encounter any of these gaps in practice, please contact us with the documentation and we will update this article with verified primary-source language.

14. How North Dakota Pattern #44 fits the 50-state series

ND Pattern #44 is the middle-ground “covered for everything except obesity” state — neither a pure-exclusion state nor a positive-coverage state. The 43-state series to date documents five coverage-architecture types:

14.1 ND vs. Vermont (Pattern #41) — closest categorical peer

Both states cover Wegovy MACE + Wegovy MASH + Zepbound OSA. Key differences:

• Zepbound OSA restrictiveness: ND requires 6-month CPAP failure AND 6-month semaglutide-or-equivalent comprehensive weight-management program; VT requires only CPAP prescribed (lowest CPAP-prerequisite bar in the series). ND’s 10% reauthorization weight-loss threshold vs. VT’s 5%.
• Antipsychotic-induced weight gain coverage: ND covers Ozempic / Victoza without PA via T43.505 diagnosis codes; VT’s PDL does not explicitly address this.
• Imcivree: ND explicitly covers Imcivree for POMC / PCSK1 / LEPR / Bardet-Biedl; VT’s PDL position on Imcivree is UNVERIFIED.
• Low-cost AOMs (phentermine, bupropion, naltrexone, topiramate): ND covers without PA via obesity diagnosis code; VT excludes them under the categorical bundled exclusion.
• Architecture: ND is FFS-dominant + BCBSND-only expansion MCO (1915(b) waiver); VT is purely FFS-only with no MCOs.
• Legislative rejection: ND HB 1451 / HB 1452 failed 12-81 / 11-82 on House floor (most decisive in series); VT H.765 / S.164 stalled in committee without floor vote.

14.2 ND vs. Montana (Pattern #46) — pure categorical peer

MT is a clean categorical chronic-weight-management exclusion (“weight-loss medications” Not Covered bucket in DPHHS Prescription Drug Program Manual); ND covers more carve-outs than MT (Wegovy MASH + antipsychotic-induced + Imcivree explicitly named on the ND PDL while MT’s carve-outs are UNVERIFIED). MT uses PCCM (Passport to Health) for traditional Medicaid; ND uses FFS for traditional + BCBSND-only for expansion. Both states had decisive 2025 legislative rejections (MT SB 417 died 11-1 in committee March 1, 2025; ND HB 1451 failed 12-81 on House floor February 12, 2025).

14.3 ND vs. Kansas (Pattern #43) — inverse-trajectory comparison

KS covers Wegovy + Zepbound for standalone obesity at adult BMI ≥ 30 or ≥ 27 with comorbidity; ND does NOT. KS LOOSENED criteria in 2024-2025 by de-listing both drugs from Table 4; ND legislators rejected HB 1451 by 12-81. Both states are non-expansion states except ND adopted expansion in 2014 while KS remained non-expansion. KS uses three-MCO architecture; ND uses FFS-dominant + BCBSND-only.

14.4 ND vs. Rhode Island (Pattern #40) — inverse coverage trajectory

RI currently covers baseline AOM (Wegovy, Zepbound, Saxenda, Contrave for obesity) but faces a governor-proposed October 1, 2026 sunset; ND excludes baseline AOM and rejected coverage 12-81 in February 2025. Where RI patients ask “will my existing coverage survive the legislature?” and ND patients ask “do I qualify for any of the indication-specific carve-outs?”

15. What North Dakota Medicaid beneficiaries should do right now

If you have established cardiovascular disease (prior MI, or prior stroke + PAD) AND are aged 55-74 AND have BMI 27.0-34.9 AND do not have diabetes (A1c normal off Rx) AND are on lipid-lowering + antiplatelet therapy: you may qualify for the Wegovy SELECT/MACE carve-out. Plan ahead for the 12-16 week Ozempic 2 mg (or Rybelsus 14 mg for oral) step-through requirement BEFORE Wegovy can be initiated. If you are a current tobacco user, complete tobacco-cessation counseling within 12 months of your PA submission. Ask your prescriber to submit the drug-specific Wegovy PA form via Acentra Health at 855-207-0250. Initial approval is for 12 months; reauthorization requires 5% weight loss / BMI loss or documented no CV event after a 5% loss.

If you have biopsy-proven or non-invasive-test-confirmed F2/F3 MASH: you may qualify for either the preferred Ozempic / Victoza MASH pathway (direct prescription) or the non-preferred Wegovy MASH pathway (with Ozempic 2 mg step-through). Engage an endocrinologist, gastroenterologist, or hepatologist to prescribe or co-sign the PA. Document F2/F3 fibrosis via biopsy, VCTE, ELF score, MR-PDFF, or MRE. If you have any history of alcohol use within the past 5 years, demonstrate sustained abstinence with PEth < 20 ng/mL before submission.

If you have moderate-to-severe OSA (AHI > 15 on in-lab attended PSG) AND BMI ≥ 30 AND no T2D: you face the most restrictive OSA carve-out in the 43-state series. You will need: a sleep-medicine specialist (neurologist, pulmonologist, otolaryngologist, or other sleep medicine specialist) prescribing or consulting; 6-month documented CPAP failure (AHI > 15 despite CPAP); 6-month documented participation in a comprehensive weight-management program with semaglutide (or phentermine / bupropion / naltrexone / topiramate fallback if semaglutide is not tolerated). Be prepared for the PA approval to be for Mounjaro (not Zepbound) under the “most cost-effective tirzepatide product” clause. Reauthorization at 12 months requires ≥ 20% AHI decrease OR OSA-severity-status change AND ≥ 10% weight loss from baseline.

If you are on an antipsychotic with documented weight gain: Ozempic and Victoza (brand) are covered without PA. Your prescriber should ensure the pharmacy claim is submitted with one of the three ICD-10 diagnosis codes T43.505A, T43.505D, or T43.505S attached. The claim should adjudicate at the point of sale.

If you have confirmed POMC / PCSK1 / LEPR deficiency or Bardet-Biedl syndrome: Imcivree (setmelanotide) is covered with PA. Initial approval is 4 months for POMC / PCSK1 / LEPR or 6 months for Bardet-Biedl. BMI > 30 (adult) or > 95th percentile (pediatric) required.

If you have obesity without one of the above qualifying indications: the only AOMs covered without PA are phentermine, bupropion, naltrexone, and topiramate (separate components). Wegovy, Zepbound, and Saxenda for standalone obesity are NOT covered.

If you have T2D: the standard T2D pharmacy pathway applies. Ozempic, Rybelsus, and brand-required Victoza are preferred (no PA). Generic liraglutide, Trulicity, and Mounjaro require PA with the standard T2D criteria (A1c ≤ 7% / TIR > 70% glycemic goals, 90-day triple-combination step-therapy, endocrinology / diabetes-specialist prescribing or consultation).

If you have none of these qualifying indications and want GLP-1 access for obesity: practical paths are (1) NovoCare Wegovy cash-pay ($199-$349/month standard pens; $399/month HD pen; $149/month oral semaglutide tablets per May 15, 2026 NovoCare verification); (2) LillyDirect Zepbound vials at $299-$699/month; (3) LillyDirect Foundayo (orforglipron, FDA-approved April 1, 2026) at $149/month self-pay; (4) patient assistance programs (Novo Nordisk PAP, Lilly Cares) for income-tested support; (5) LegitScript-approved compounded telehealth at $99-$199/month for semaglutide and $149-$249/month for tirzepatide (with the FDA compounding-resolved caveat for both molecules); (6) if you transition above 138% FPL to commercial ACA-marketplace coverage, the ND 2025 EHB Benchmark Plan covers GLP-1 / GIP for morbid obesity (commercial coverage is more generous than ND Medicaid on the obesity indication — the inverse of the usual structure).

If your PA is denied: do not give up after the first denial. Call Acentra Health provider relations at 1-866-773-0695 to verify denial rationale — many ND Medicaid AOM denials are documentation deficiencies recoverable via re-submission with stronger evidence. If re-submission fails, file the SFN 162 Request for Hearing within 30 days of the denial notice mailing date. Mail to Appeals Supervisor, Legal Division, 600 E Boulevard Ave., Dept. 325, Bismarck, ND 58505-0250; or phone (701) 328-2311 / (800) 472-2622; or email dhslau@nd.gov. If the NDDHHS hearing officer affirms the denial, file an appeal to ND District Court under N.D.C.C. ch. 28-32.

Related coverage

• Hawaii Med-QUEST GLP-1 Coverage (Pattern #50 CAPSTONE / SERIES COMPLETE) — opposite legislative direction in 2025-2026 cycle: where ND House DECISIVELY REJECTED HB 1451 12-81 and HB 1452 11-82 on 02/12/2025 (most decisive legislative no-vote on Medicaid GLP-1 coverage in the entire 50-state series), HI SB 3195 (Sen. Kurt Fevella R-Ewa Beach, bipartisan, 2026 Regular Session) remains live and would scrap the AlohaCare-verbatim-codified categorical exclusion AND prohibit PA. ND is the middle-ground “covered for everything except obesity” state with explicit Wegovy MACE + Wegovy MASH + Zepbound OSA + antipsychotic-induced + Imcivree carve-outs on the PDL; HI carve-outs UNVERIFIED (binary-PDF MCO formularies). ND FFS-dominant + BCBSND-only expansion 1915(b) waiver vs. HI 5-MCO mandatory managed care under 32-year continuous 1115 demonstration (longest in series). Pattern #50 closes the 50-state series
• Alaska Medicaid GLP-1 Coverage (Pattern #49) — opposite carve-out posture: where ND is the middle-ground state with explicit Wegovy MACE + Wegovy MASH + Zepbound OSA + antipsychotic-induced + Imcivree carve-outs, AK has NO published carve-outs — Wegovy / Zepbound / Saxenda are absent from any class of the March 1, 2026 PDL and no Alaska-specific policy bulletin operationalizes the federal floor for SELECT/MACE or SURMOUNT-OSA; AK is FFS-only with no MCOs (ND uses FFS-dominant + BCBSND-only expansion MCO under 1915(b) waiver); AK uses Prime Therapeutics Medicaid Administration (formerly Magellan Rx) while ND uses Acentra Health PBM; AK has the largest US geography (663,267 sq mi, ~17% of US land area; ~1.3 people per sq mi) and the largest tribal-health overlap in the series (229+ federally recognized tribes); both are Medicaid-expansion states (AK via Gov. Walker executive action September 1, 2015; ND via 1/1/2014 ACA expansion); ND legislators rejected coverage 12-81 / 11-82 (most decisive in series) vs. no comparable AK AOM-mandate bill identified
• Wyoming Medicaid GLP-1 Coverage (Pattern #47) — closest categorical-AOM-exclusion-with-FDA-label-carve-ins peer to ND in the Plains/Mountain-West cohort: WY covers the SAME three indications (Wegovy CV, Wegovy MASH, Zepbound OSA) but WY’s Wegovy CV criteria are materially LESS restrictive (no age 55-74 bracket, no T2D-negativity requirement, no off-label Ozempic 2 mg step-through, no lipid + antiplatelet concurrent therapy requirement, no tobacco-cessation requirement — just verbatim FDA SELECT label adoption) and WY’s Zepbound OSA criteria are materially LESS restrictive (no 6-month CPAP failure prerequisite, no comprehensive weight-management program with semaglutide prerequisite, 5% wt-loss at 6 months vs. ND’s 10% at 12 months). WY uses FFS-only with WYhealth CME + OptumRx as pharmacy benefit administrator after April 15, 2026 migration; ND uses FFS-dominant + BCBSND-only Medicaid Expansion MCO + Acentra Health PBM. WY had no AOM legislation in 2024-2026; ND legislators rejected coverage 12-81 / 11-82. WY non-expansion; ND adopted expansion 1/1/2014. WY ~59,714 enrollment (smallest US state by population); ND 105,000
• Montana Medicaid GLP-1 Coverage (Pattern #46) — categorical “weight-loss medications” Not Covered bucket under DPHHS / Mountain-Pacific Quality Health PA after HB 245 made expansion permanent and SB 417 (Sen. Ellie Boldman AOM mandate) died 11-1 in committee March 1, 2025; PCCM (Passport to Health) architecture; pure-categorical contrast to ND’s middle-ground posture
• South Dakota Medicaid GLP-1 Coverage (Pattern #45) — sister Dakotan state with the OPPOSITE architectural choice: where ND’s middle-ground codifies carve-outs explicitly (Wegovy MACE + Wegovy MASH + Zepbound OSA + antipsychotic-induced no-PA + Imcivree + low-cost AOMs) under a comprehensive Pharmacy Coverage Policy Manual, SD codifies NOTHING — functional AOM exclusion by ABSENCE (no codified categorical sentence; the OptumRx SD-specific GLP-1 PA form pre-codes ONLY T2D as the indication checkbox); ND HB 1451 / HB 1452 FAILED 12-81 / 11-82 on House floor 02/12/2025 vs. SD no AOM-specific bill in 2024-2025 sessions; both are sparsely populated with tribal-health overlap; SD ballot-initiative expansion (Amendment D 2022) plus uniquely constitutionalized 90% FMAP trigger on Nov 3, 2026 ballot vs. ND 1/1/2014 ACA expansion
• Idaho Medicaid GLP-1 Coverage (Pattern #48) — codification contrast to ND in the adjacent Mountain-West cohort: where ND codifies the middle-ground carve-out architecture explicitly in PDL 2026.4, ID has NEITHER a codified categorical exclusion sentence NOR codified carve-outs — IDAPA 16.03.09.662 does NOT enumerate anti-obesity drugs as an excluded class. ID’s exclusion operates through PDL non-preferred status + PA criteria + the absence of an obesity-indication PA pathway. Wegovy MACE / Zepbound OSA / Wegovy MASH are presumptively covered under federal rebate framework but practical PA pathways UNVERIFIED. Active legislative repeal trajectory (HB 138 defeated 2025, HB 345 signed MCO-by-2030, HB 913 signed April 11, 2026 work-requirements-by-2027) + state-employee plan dropped GLP-1 obesity coverage Nov 1, 2025
• Kansas Medicaid GLP-1 Coverage (Pattern #43) — inverse trajectory: positive-coverage non-expansion state that LOOSENED AOM criteria 2024-2025 by de-listing Wegovy + Zepbound from Table 4 (BMI ≥ 40 severe-obesity gate eliminated); ND legislators rejected analogous coverage 12-81 on the House floor
• Delaware Medicaid GLP-1 Coverage (Pattern #42) — positive-coverage stable state with unified DMAP PDL across 3 MCOs (Wegovy + Saxenda preferred; Zepbound clinical-exception pathway)
• Vermont Medicaid GLP-1 Coverage (Pattern #41) — closest categorical peer: VT covers Wegovy MACE + Wegovy MASH + Zepbound OSA carve-outs but excludes baseline AOM (categorical bundled exclusion); VT’s Zepbound OSA carve-out is materially less restrictive than ND’s (CPAP prescribed vs. ND’s 6-mo CPAP + 6-mo semaglutide); FFS-only architecture vs. ND’s FFS + BCBSND-only expansion
• Rhode Island Medicaid GLP-1 Coverage (Pattern #40) — first state in series with active coverage + governor-proposed October 1, 2026 sunset; inverse coverage posture to ND
• Maine MaineCare GLP-1 Coverage (Pattern #39) — categorical exclusion with NO Wegovy MASH carve-out; LD 480 killed March 20, 2025
• Nebraska Medicaid GLP-1 Coverage (Pattern #38) — categorical exclusion with 45-74 age gate + 6-month MASH prerequisite; LB907 Indefinitely Postponed
• Utah Medicaid GLP-1 Coverage (Pattern #37) — 6/30/2026 sunset of in-lab attended PSG carve-out
• West Virginia Medicaid GLP-1 Coverage (Pattern #36) — categorical exclusion with Wegovy CV + Zepbound OSA + Wegovy MASH carve-outs via WVU RDTP
• Mississippi Medicaid GLP-1 Coverage (Pattern #35) — only non-expansion southern positive-coverage state; SPA 23-0013 carve-back-in with pediatric ages 12+ pathway
• 50-state Medicaid GLP-1 coverage map — full series overview with pattern taxonomy
• GLP-1 insurance coverage hub — Medicare, Medicaid, and commercial coverage landscape
• GLP-1 insurance dropped coverage appeal playbook — denial-recovery patterns applicable across states

Primary sources

1. ND Medicaid PDL Version 2026.4 (Effective April 1, 2026) — Acentra Health / NDDHHS Medical Services Division
2. ND Medicaid PDL landing (Acentra)
3. ND Medicaid Prior Authorization landing (Acentra)
4. General Prior Authorization Form (Acentra)
5. Acentra PA form lookup tool
6. NDDHHS Medicaid landing
7. NDDHHS Medicaid FAQ
8. NDDHHS Client Rights and Appeals (SFN 162, DN 263)
9. NDDHHS File an Appeal — Medicaid
10. NDDHHS Pharmacy Providers
11. NDDHHS Service Authorizations Manual
12. NDDHHS Medicaid Expansion landing
13. BCBSND Medicaid Expansion contract announcement
14. BCBSND Medicaid Expansion provider hub
15. ND HB 1451 overview (69th Legislative Assembly)
16. ND HB 1451 text (LegiScan)
17. ND HB 1452 overview
18. ND HB 1452 full text
19. Nelson testimony on HB 1451
20. ND Insurance Department — 2025 EHB Benchmark Plan FAQ
21. KFF Medicaid in North Dakota fact sheet (May 2025)
22. KFF Medicaid Coverage of and Spending on GLP-1s (Jan 2026)
23. KXNET coverage of HB 1451