Family of drug-specific prior authorization forms for Canada Life workplace drug plans.
- Completed by
- Prescribing physician (plan member completes their part)
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
Medavie Blue Cross Prior Authorization Forms
Medavie Blue Cross requires pre-approval before certain drugs are reimbursed under a member's group plan, using drug-specific or drug-class forms listed in its online resources library. Clinicians meet them when prescribing products such as Abrilada (adalimumab), Aimovig (erenumab) or Adlyxine (lixisenatide). Medavie reviews each request against payment criteria developed with independent health care consultants.
Who completes it
The member completes Section 2 (patient information, coordination of benefits and signed authorization), a coordinating pharmacy or patient support program may complete Section 1, and the prescriber completes Section 3 and signs the Health Professional Statement.
Submitting and payment
- How to submit it
- Fax the completed form in confidence or mail it to Medavie Blue Cross, using the fax line and mailing address for Quebec residents or the ones for residents of all other provinces.
- Who pays
- The form states that any costs of completing it, or of obtaining additional medical information, are the member's responsibility.
Good to know
- Incomplete forms cannot be processed; Section 3A drug information is mandatory, including diagnosis, date treatment started, expected duration and the specialty of the physician who initiated treatment.
- Approval may be limited to a set period or quantity, and for some medications depends on confirmed enrolment in the patient support program.
- Renewals are considered on request from the patient or member and should include the physician's information supporting continued use of the medication.
- For Quebec residents, criteria are adjusted to RAMQ requirements, and a Mesure du patient d'exception request also needs Medavie's Patient d'exception form.
Get the official form
Download the current version from the source each time; forms change without notice.
Prior authorization forms
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
Who signs the Medavie Blue Cross prior authorization form?
Two signatures are needed. The patient signs the Part C authorization in Section 2, and the prescriber signs the Health Professional Statement, certifying they reviewed all pages and that the information is true, correct and complete. The prescriber also gives a permit number, specialty and clinic contact details.
What does a Medavie Blue Cross prior authorization decline mean?
Medavie states that when it declines a request it is denying payment for the product, not challenging the physician's medical opinion or rendering one. The form also notes that prior authorization coverage depends on the patient remaining a Medavie Blue Cross cardholder or beneficiary.
What if the patient already bought the drug?
Section 2 asks whether the prescription has already been purchased. If it has, the member attaches the paid-in-full receipt to the request, or gives the date of the oldest receipt if receipts were already submitted to Medavie Blue Cross.