Family of drug-specific prior authorization forms for Medavie group drug plans.
- Completed by
- Prescribing physician (plan member completes their part)
- Issued by
- Medavie Blue Cross
- Format
- Language
- English
Canada Life Prior Authorization Forms (M6453)
Canada Life workplace drug plans require prior authorization for certain prescription drugs, using drug-specific forms that share the M6453 code, such as those for Orencia, Verzenio or adalimumab. Each collects information from the member and physician so Canada Life can judge whether the drug is reasonable treatment, whether other or lower-cost drugs should come first, and whether another program covers it.
Who completes it
The plan member completes the patient information sections and signs the consent; the prescribing physician completes the physician information sections and signs with their licence number.
Submitting and payment
- How to submit it
- Send all pages to Canada Life's Drug Claims Management by mail, fax or email, as printed on each form; Canada Life notes email is not secure.
- Who pays
- Any cost of completing the forms is the responsibility of the plan member or patient.
Good to know
- Plans may require the drug to be bought from a Canada Life designated pharmacy, with a health case manager helping set up the prescription once the claim is approved.
- Where a provincial program covers the drug, the plan requires the member to apply there; Manitoba, Saskatchewan and B.C. pharmacare programs are open to all residents.
- Plans may limit coverage of an originator biologic to that of a biosimilar, or limit a drug's covered cost to a lower-cost alternative.
- The forms can be printed or filled in Adobe Reader XI or higher, not a browser, then saved; individual plans sold through an advisor use separate forms.
Get the official form
Download the current version from the source each time; forms change without notice.
Prior authorization forms
Fill it with Vero
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.
How this list is checked
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
How do I know if a drug needs Canada Life prior authorization?
Members with an online Canada Life account can sign in to check whether their prescribed drugs are covered and, if they are, request pre-approval by completing the applicable form. Drug-specific forms share the M6453 code, for example the forms for Orencia, Verzenio or adalimumab.
What is a Canada Life health case manager?
Some plans require members on prior authorization drugs to join Canada Life's Health Case Management program. The case manager works with the member and physician on treatment options, helps them access patient support programs and other benefits, and provides ongoing communication and follow-up for a period.
Why does Canada Life ask about provincial coverage?
Its general information sheet says some drugs are eligible through a provincial drug program, and the benefits plan requires the member to apply there when one is available. Registration in these programs is free and can reduce the member's out-of-pocket cost for the drug.