Canada Life plan members use this four-page prior authorization form to request coverage of medical cannabis under a workplace drug plan. The physician confirms the patient is authorized to possess cannabis for medical purposes, gives the dosage form and regimen, and selects one of four indications, from multiple sclerosis spasticity to palliative symptoms, with the date of diagnosis and expected duration.
The plan member completes the patient information page, including any medical cannabis coverage with another carrier, and signs; the physician completes the physician information and signs with their licence number.
Download the current version from the source each time; forms change without notice.
Drug Prior Authorization Form – Medical Cannabis
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Canada Life workplace plans review medical cannabis through prior authorization using this form. It lists four indications: spasticity or neuropathic pain with multiple sclerosis, chemotherapy-induced nausea and vomiting or neuropathic pain with cancer, anorexia or neuropathic pain with HIV/AIDS, and symptoms associated with palliative care.
The physician confirms whether the patient is authorized to possess cannabis for medical purposes, gives the prescribed dosage form and regimen, selects the diagnosis or indication with the date of initial diagnosis, states the anticipated duration of treatment, and signs with their licence number.
Send all pages to Canada Life's Drug Claims Management by mail, fax or email, as printed on the form. Canada Life notes that email is not a secure medium, so anyone concerned about their medical information being intercepted can use mail or fax instead.