Industry initial medical statement used for Empire Life group short- and long-term disability claims.
- Completed by
- Attending physician or other medical provider
- Issued by
- Empire Life
- Format
- Fillable PDF
- Language
- English
Empire Life Drug Prior Authorization Forms
Empire Life group drug plans need approval before paying for certain drugs, and the drug-specific form is pulled from Express Scripts Canada's form search by carrier, group number and province. Clinicians meet these when prescribing drugs such as Ozempic, Mounjaro, Dupixent or Aimovig. The completed form goes to Express Scripts Canada for review.
Who completes it
The patient completes Part A and the prescribing physician completes Part B of each drug-specific form, following the three steps set out on the Express Scripts Canada page.
Submitting and payment
- How to submit it
- Fax or mail the completed form to Express Scripts Canada Clinical Services in Mississauga, Ontario; the fax number and mailing address are listed on the Express Scripts Canada form search page.
Good to know
- Empire's Prior Authorization Approval Guidelines (GRP-5003-EN) state that all applicable prior therapies must be listed on the form for the request to be considered for approval.
- To be considered, the medication must be administered outside an inpatient hospital, according to the same Empire Life guidelines.
- The guidelines group drugs by indication, including diabetes (Ozempic, Mounjaro, Rybelsus), weight management (Wegovy, Saxenda, Zepbound), migraine (Aimovig, Emgality, Qulipta) and skin conditions (Dupixent).
- Coverage of a listed drug still depends on the member's plan design, and Empire notes the guidelines are not an exhaustive list of approval criteria.
Get the official form
Download the current version from the source each time; forms change without notice.
Prior Authorization Program (Express Scripts Canada) – Empire Life
Fill it with Vero
If your copy of the form is a fillable PDF, upload it 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
Where do I find the Empire Life prior authorization form for a specific drug?
Use Express Scripts Canada's prior authorization form search. Choose Empire Life as the carrier, enter the plan's group number and select the province. The search returns the medications that need prior authorization under that plan, with the matching forms, so the patient's group number is needed to run it.
Which drugs need prior authorization under Empire Life plans?
Empire's Prior Authorization Approval Guidelines, dated November 2025, list them by indication, from asthma biologics and cancer drugs to diabetes agents such as Ozempic and Mounjaro, the FreeStyle Libre sensor, and weight-management drugs such as Wegovy. Eligibility still varies by plan design, so the search for the patient's group shows what applies.
Is the Empire Life prior authorization form available in French?
Yes. Express Scripts Canada's prior authorization page has a French version, and the forms are offered in English and French. Accessible formats are also available on request. Either way, the patient completes Part A, the prescriber completes Part B, and the form is faxed or mailed to Express Scripts Canada.