Manulife's copy of the industry initial medical statement; the same form is used for short- and long-term disability claims.
- Completed by
- Attending physician or other medical provider
- Issued by
- Manulife
- Format
- Language
- English
Manulife Drug Prior Authorization Forms (GL5197E)
Manulife group drug plans need approval before paying for drugs on their Prior Authorization list, and the form for a drug is found by its name or DIN in Manulife's search tool. Clinicians meet these when prescribing drugs such as Ozempic (semaglutide). Manulife's Prior Authorization Team assesses the form against the drug's initial or renewal criteria and notifies the plan member.
Who completes it
The plan member completes Sections 1 to 3 (plan details, other coverage, provincial plans and patient assistance programs) and signs Section 7; the prescribing physician completes Section 4 medical information, Section 5 drug history and Section 6 physician information.
Submitting and payment
- How to submit it
- The plan member submits all pages through the Plan Member Secure Site or mobile app as an 'Estimate' claim, or by mail or fax to Manulife's Prior Authorization Team, with separate addresses for Quebec and other provinces.
- Who pays
- The form states that all costs incurred to complete it are the plan member's responsibility.
Good to know
- Section 4 has separate initial and renewal criteria for each indication; on the Ozempic form, renewal asks for objective evidence of continued benefit, such as a decrease in HbA1c from baseline.
- If no previous therapies were tried, Section 5 asks for the rationale, such as a risk of drug interaction, a contraindication or another medical reason.
- For Ontario patients who qualify for the Exceptional Access Program, a copy of the EAP approval or denial must accompany requests for EAP drugs.
- Approvals may be time-limited; Manulife states the approval duration at approval and may ask for more information to assess continued coverage.
Get the official form
Download the current version from the source each time; forms change without notice.
Drug Prior Authorization - Group Benefits
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
How do I find the right Manulife prior authorization form?
Search Manulife's Drug Prior Authorization Forms tool by medication name or Drug Identification Number (DIN), then download the form for that drug. Manulife asks that the most current, unaltered version be completed and signed, so download a fresh copy for each request rather than reusing an old one.
What does the prescriber fill in on a Manulife prior authorization form?
Section 4 asks for drug strength and dosage, where treatment will be given, and yes or no answers to the criteria for the selected diagnosis. Section 5 lists previous and current therapies with dates and outcomes. Section 6 records the physician's college or licence number, specialty and signed certification.
How is a Manulife prior authorization decision communicated?
Manulife notifies the plan member. Members registered on the Plan Member Secure Site with an email address get an email when the decision appears on their claims statement; others are notified by mail. If the patient already bought the drug, receipts go in with an Extended Health Care Claim form.