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 GL4445: Brand-Name Drug Approval Request
Manulife group plans cover a prescribed interchangeable drug only up to the lowest-cost interchangeable price. This two-page form requests an exception so the brand name is reimbursed up to the reasonable and customary price of the product dispensed. It is considered only when the prescribing physician indicates the lowest-cost interchangeable drug cannot be tolerated or is ineffective for the patient.
Who completes it
The plan member completes Section 1 (plan, patient and DIN details) and signs Section 3; the prescribing physician completes Section 2, the physician's statement.
Submitting and payment
- How to submit it
- The plan member mails or faxes the completed form to Manulife Group Benefits Health and Dental Claims, using the Quebec address or the one for all other provinces printed in Section 4.
- Who pays
- The physician's statement notes that any charges for completing the form are the plan member's responsibility.
Good to know
- The physician must select a medical reason, either adverse reaction or therapeutic failure, showing why the lowest-cost interchangeable drug cannot be tolerated or is ineffective.
- Section 2 identifies the drug prescribed by chemical name, dosage form and strength, while the plan member enters the product's Drug Identification Number (DIN) in Section 1.
- If the exception is approved, reimbursement rises to the reasonable and customary price of the product dispensed instead of the lowest-cost interchangeable price.
- The current version is GL4445E (02/2025), listed in English on Manulife's find-a-form page for group benefits.
Get the official form
Download the current version from the source each time; forms change without notice.
Request for Approval of Brand-Name Drug – 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
When does Manulife pay for a brand-name drug instead of the generic?
Manulife considers the cost of the prescribed brand only when the prescribing physician indicates that the lowest-cost interchangeable drug cannot be tolerated or is ineffective for the patient. On GL4445 the physician records this by choosing adverse reaction or therapeutic failure, then signs and dates the physician's statement.
Who pays for completing Manulife form GL4445?
The plan member. A note at the top of Section 2, the physician's statement, says any charges for completing the form are the plan member's responsibility. The plan member also completes Sections 1 and 3 and sends the finished form to Manulife.
Where is Manulife GL4445 sent?
To Manulife Group Benefits Health and Dental Claims. Section 4 gives one mailing address and fax line for members who live in Quebec and another for members in all other provinces, so the plan member uses the one that matches their province of residence.