Yes! You can use AI to fill out Manulife Group Benefits Drug Prior Authorization Form – Mounjaro (Tirzepatide) (GL5197E)
The Manulife Group Benefits Drug Prior Authorization â Mounjaro (Tirzepatide) form (GL5197E) collects plan member, patient, and prescribing physician information needed for Manulife to assess whether Mounjaro is eligible for coverage under the memberâs drug plan. It includes questions about other group coverage, provincial program applications/decisions, patient assistance programs, diagnosis and clinical criteria (initial and renewal), and prior medication history, plus required consents and signatures. Completing it accurately helps avoid delays and supports a fair medical-necessity review, but does not guarantee approval. Today, this form can be filled out quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.
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Form specifications
| Form name: | Manulife Group Benefits Drug Prior Authorization Form – Mounjaro (Tirzepatide) (GL5197E) |
| Number of pages: | 4 |
| Language: | English |
| Categories: | insurance forms, prior authorization forms, Manulife forms, benefit forms, health benefit forms, authorization forms |
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How to Fill Out GL5197E (Mounjaro) Online for Free in 2026
Are you looking to fill out a GL5197E (MOUNJARO) form online quickly and accurately? Instafill.ai offers the #1 AI-powered PDF filling software of 2026, allowing you to complete your GL5197E (MOUNJARO) form in just 37 seconds or less.
Follow these steps to fill out your GL5197E (MOUNJARO) form online using Instafill.ai:
- 1 Go to Instafill.ai and upload the Manulife GL5197E Drug Prior Authorization – Mounjaro (Tirzepatide) form (or select it from the form library).
- 2 Enter plan member and patient details (names, dates of birth, address, phone/email, relationship, and plan identifiers such as contract and certificate numbers).
- 3 Complete coverage coordination questions (other group plan coverage, whether the drug is covered/declined elsewhere, and whether benefits recently transferred to Manulife), and attach any required proof/decline notices if applicable.
- 4 Have the prescribing physician complete provincial plan information (application/approval status and reasons if declined) and patient assistance program details (enrollment, ID, case manager).
- 5 Have the prescribing physician enter medical information for Mounjaro (strength/dose, administration location, diagnosis selection, and initial vs. renewal criteria responses including metformin history, GLP-1 combination use, dose limits, and evidence of benefit for renewals).
- 6 Provide drug history (previous/current therapies, dates, outcomes, and medical rationale) and complete physician information, certification, signature, and date.
- 7 Review the authorization/consent section, add the plan member signature and date, then submit via the Plan Member Secure Site or send by mail/fax as instructed, keeping a copy for your records.
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Frequently Asked Questions About Form GL5197E (Mounjaro)
This form collects the medical and plan information Manulife needs to assess coverage for Mounjaro under a drug plan that requires prior authorization. Submitting the form helps Manulife decide whether the medication meets your planâs criteria, but it does not guarantee approval.
Section 1 (plan member/patient information), Section 3 (Patient Assistance Program), and Section 7 (authorization/signature) are completed by the plan member. Sections 2, 4, 5, and 6 (provincial plan details, medical criteria, drug history, and physician info/signature) must be completed by the prescribing physician.
Have your plan contract number, plan member certificate/ID number, plan sponsor (employer) name, and both the plan member and patient personal details (address, date of birth, phone). If applicable, also gather details about any other group drug plan and any provincial program application/decision.
If you had prior coverage for this drug before moving to Manulife, attach proof of payment such as a pharmacy receipt showing payment from the prior insurer or an Explanation of Benefits. If another group plan declined coverage, attach the decline notice (and for renewals, a current decline notice is required).
Answer âYesâ to the other group plan question and provide the other insurerâs name and plan identifiers. If the drug is not covered by the other plan, you must attach the other planâs decline notice so Manulife can assess whether it can be approved under your Manulife plan.
Indicate that your plan sponsor transferred benefits and that you were previously receiving coverage for the drug. Attach proof of payment (receipt or prior insurer Explanation of Benefits) as requested and follow the formâs instruction to proceed to the authorization section.
Often yesâManulife plans typically supplement provincial coverage, so you or your doctor may need to apply to the applicable provincial program first. In Ontario, if the drug is considered under the Exceptional Access Program (EAP), include a copy of the EAP approval or denial with this form.
The physician must confirm the diagnosis of Type 2 diabetes and answer questions about metformin use/response or intolerance/contraindication, use with diet and exercise, whether Mounjaro will be combined with other GLP-1 analogs, and whether the dose will exceed 15 mg once weekly. These answers are used to determine if the request meets initial or renewal criteria.
The form notes that initial approval is limited to 12 months. For renewal, the physician must provide objective evidence of continued benefit (for example, a decrease in HbA1c) and confirm ongoing use criteria such as diet/exercise and dosing limits.
The prescribing physician should list previous and current therapies for the selected diagnosis, including drug names and start/end dates, and indicate outcomes such as intolerance/adverse events or inadequate response. If no previous therapies were tried, the physician must document the medical rationale (e.g., contraindication or interaction risk).
You can submit using the âSubmit a Claimâ feature on the Plan Member Secure Site, or mail/fax it to Manulife. Quebec residents mail to PO Box 2580, Station B, Montreal QC H3B 5C6; residents outside Quebec mail to PO Box 1653, Waterloo ON N2J 4W1; fax is 1-855-752-0404 for both.
If youâre registered for the Plan Member Secure Site and provided an email address, youâll receive an email notification when the decision is available on your claims statement. If youâre not registered, Manulife will notify you by mail.
YesâAI tools can help you organize and auto-fill plan member sections accurately and reduce errors. Services like Instafill.ai can extract details from your documents and auto-populate form fields to save time (you should still review everything before signing).
Upload the PDF to Instafill.ai, then add supporting documents (e.g., insurance card details, receipts, decline letters) so it can map information to the correct fields. Review the auto-filled entries, export the completed PDF, and then submit it to Manulife via the Secure Site or by mail/fax as instructed.
If the form is a flat/non-fillable PDF, Instafill.ai can convert it into an interactive fillable form and then auto-fill the fields. After conversion, verify the entries and ensure required signatures (plan member and physician) are completed before submission.
Compliance GL5197E (Mounjaro)
Validation Checks by Instafill.ai
1
Validates required plan identifiers are present and non-empty
Checks that Plan contract number, Plan member certificate number, and Plan sponsor are provided because they are essential to locate the correct group plan and member record. The validation should reject submissions where any of these identifiers are blank, whitespace-only, or clearly placeholder text (e.g., âN/Aâ when a value is required). If validation fails, the request should be returned for completion to prevent misrouting or inability to adjudicate the prior authorization.
2
Ensures plan contract number and certificate number follow allowed character rules
Validates that plan contract number and certificate number contain only expected characters (letters, digits, and permitted separators such as hyphens/spaces) and are within reasonable length limits. This reduces downstream matching errors caused by OCR artifacts or accidental punctuation. If the format is invalid, the system should flag the field and require correction before submission.
3
Validates member and patient names are complete and plausibly formatted
Checks that Plan member name and Patient full name include at least a first and last name, and that the middle initial (if present) is a single letter. It should also detect obviously invalid entries (numbers-only, excessive symbols, or repeated characters) that indicate data entry errors. If validation fails, the submission should be held and the user prompted to correct the name fields to avoid identity mismatches.
4
Validates date of birth fields use the required format and are real calendar dates
Ensures Plan member date of birth and Patient date of birth match the required format (dd/mmm/yyyy) and represent valid dates (e.g., not 31/Feb/2020). This prevents parsing errors and incorrect age calculations used in eligibility and clinical review. If validation fails, the form should be rejected with a clear message indicating the expected date format.
5
Checks date of birth plausibility and age constraints
Validates that both DOBs are not in the future and fall within plausible human ranges (e.g., not older than 120 years). It should also flag cases where the patient is a minor but the relationship indicates something inconsistent (e.g., âspouseâ with a child-aged DOB). If validation fails, the system should request confirmation/correction to prevent coverage and consent issues.
6
Validates Canadian address completeness and province/postal code consistency
Checks that Plan member address, City/Town, Province, and Postal code are all present and that the postal code matches Canadian format (A1A 1A1) and is consistent with the selected province where feasible. This is important for mailing decisions (Quebec vs outside Quebec) and for accurate member records. If validation fails, the submission should be returned for address correction to avoid misdelivery and processing delays.
7
Validates patient daytime phone number and extension formatting
Ensures the Patient preferred daytime phone number includes a valid North American numbering plan format (10 digits, allowing separators) and that the extension (if provided) is numeric and within a reasonable length. Reliable phone contact is critical for case management and missing-information outreach. If validation fails, the system should block submission or require correction depending on whether phone is mandatory for the workflow.
8
Validates patient email address format when provided
If Patient email address is entered, validates it against standard email structure (local@domain) and rejects clearly invalid values (spaces, missing domain, etc.). This matters because the form indicates email notifications may be sent via the Plan Member Secure Site workflow. If validation fails, the system should prompt the user to correct the email or leave it blank (since it is optional).
9
Enforces mutual exclusivity for Yes/No checkbox pairs across the form
Checks that for each Yes/No question (e.g., other group plan coverage, drug covered under other plan, sponsor transfer, prior coverage, provincial application, provincial approval, PAP enrollment, clinical criteria questions), exactly one option is selected. Selecting both or neither creates ambiguity and can route the request incorrectly. If validation fails, the system should require the user/physician to select a single clear answer.
10
Validates conditional completion of other group plan details
If 'Does the patient have drug coverage under any other group plan?' is Yes, requires completion of the other plan insurer name, contract number, certificate number, and the 'Is this drug covered under the other group plan?' Yes/No selection. If the answer is No, these fields should be empty (or ignored) to prevent conflicting data. If validation fails, the submission should be stopped and the missing/extra fields highlighted.
11
Requires decline reason and attachment indicator when other plan does not cover the drug
If other group plan coverage is Yes and 'Is this drug covered under the other group plan?' is No, requires a non-empty decline reason and an indication that the decline notice is attached (or a required upload in digital workflows). The form explicitly states a decline notice is needed, including for renewals, to assess approval. If validation fails, the request should be marked incomplete and not sent to clinical review.
12
Validates sponsor transfer and prior coverage logic with proof-of-payment requirement
If the plan sponsor recently transferred benefits to Manulife is Yes and previously receiving coverage for this drug is Yes, the workflow should require proof of payment/EOB attachment as stated on the form. If previously receiving coverage is No, the form routes to provincial plan questions; the system should enforce that those provincial fields are completed instead. If validation fails, the submission should be routed back for the correct supporting documentation or required provincial-plan section completion.
13
Validates provincial program section completeness when applicable
When the provincial plan section is applicable (e.g., prior coverage through previous insurer is No), requires an answer to 'Has application been made?' and, if No, requires 'Reason application not made'. It also requires an answer to 'Has the patient been approved?' and, if No, requires 'Reason provincial coverage was declined' (and, where relevant, an approval/denial document indicator such as EAP in Ontario). If validation fails, the request should be held because provincial coordination is required for correct adjudication.
14
Validates Patient Assistance Program (PAP) conditional fields
If PAP enrollment is Yes, requires a PAP ID Number and Case Manager name/contact details; if PAP enrollment is No, these fields should be blank. This ensures Manulife can coordinate with the program and avoids storing unnecessary third-party identifiers when not applicable. If validation fails, the system should prompt for the missing PAP details or clear the inapplicable fields.
15
Validates treatment administration location selection and facility details
Requires exactly one treatment administration location (Home, MD Office, Private Clinic, Hospital In-patient, Hospital Out-patient). If the location is not Home, requires facility name, telephone, address, city, province, and postal code; if MD Office is selected, requires the 'Is the MD office located in a hospital?' Yes/No response and, if Yes, the descriptive hospital administration details. If validation fails, the submission should be blocked because site-of-care affects clinical handling and potential vendor/case management routing.
16
Validates Mounjaro strength/dosage format and maximum dose consistency
Checks that Drug strength and dosage includes a numeric value and unit (e.g., mg) and is not free-text only (e.g., âas directedâ without any strength). It should also cross-check the 'Will dose exceed 15 mg once weekly?' response against the entered dosage when parseable, flagging contradictions (e.g., dosage indicates 15 mg weekly but 'exceed' marked Yes). If validation fails, the prescriber should be prompted to correct the dosage or the dose-limit answer to prevent unsafe or non-covered dosing.
17
Validates diagnosis selection and required clinical criteria completion (Initial vs Renewal)
Requires that at least one diagnosis pathway is selected (Type 2 Diabetes Mellitus or Any other diagnosis) and that the corresponding criteria questions are fully answered. For Type 2 Diabetes Mellitus, the system should ensure the relevant Initial and/or Renewal criteria fields are completed based on the request type, and that 'Any other diagnosis' includes the specific diagnosis and supporting evidence text. If validation fails, the request should not proceed to assessment because clinical eligibility cannot be determined.
18
Validates drug history entries for internal date logic and outcome completeness
For each prior therapy row with a drug name, requires a start date (yyyy/mmm) and validates that end date (if provided) is not earlier than the start date. If 'Continuing on this medication' is No, an end date should be present; if Yes, end date should be blank or treated as ongoing, and at least one outcome (intolerance or inadequate response) should be captured where applicable. If validation fails, the system should request correction because prior therapy history is central to prior authorization decisions.
19
Validates physician information and signature/date requirements
Ensures prescribing physicianâs name, specialty, office address, city, province, postal code, telephone, and fax (if required by business rules) are present and plausibly formatted. It also requires physician signature and date signed in dd/mmm/yyyy format, and validates the signed date is not in the future. If validation fails, the submission should be rejected because the authorization is not valid without complete prescriber identification and attestation.
20
Validates plan member authorization signature and date signed
Requires the plan memberâs signature and date signed (dd/mmm/yyyy) to be present and valid, and checks the date is not in the future. This is critical for consent to collect/use/disclose personal information and to process the prior authorization request. If validation fails, the request should not be processed and must be returned for proper consent completion.
Common Mistakes in Completing GL5197E (Mounjaro)
People often enter the patientâs name/DOB/address in the plan member fields (or vice versa), especially when the patient is a spouse or dependent. This can cause eligibility mismatches and delays because Manulife canât reliably link the request to the correct certificate holder. To avoid this, confirm who the plan member is (the person whose name is on the benefits card) and ensure the patient section reflects the person taking Mounjaro. AI-powered tools like Instafill.ai can help map data to the correct fields and flag inconsistencies before submission.
A very common error is entering the wrong plan contract number or certificate number, omitting leading zeros, or using an internal employer ID instead of the insurerâs identifier. This can prevent the request from being matched to the correct plan and may result in processing delays or a request for resubmission. Always copy these identifiers exactly as shown on the benefits card/plan documents, including letters, hyphens, and leading zeros. Instafill.ai can automatically format and validate these identifiers to reduce keying errors.
This form uses specific date formats (e.g., date of birth as dd/mmm/yyyy and drug history dates as yyyy/mmm), but many people enter numeric formats like 01/02/2025 or include full day/month/day in the drug history section. Incorrect formats can create ambiguity (especially with day/month swaps) and may trigger follow-up requests. Use the exact format requested (e.g., 17/Feb/1980; 2025/Feb) and keep it consistent across the form. Instafill.ai can standardize dates into the required format automatically.
Applicants frequently check a Yes/No box (e.g., other group plan coverage, provincial program application, patient assistance program) but forget to complete the required follow-up fields like insurer name, contract/certificate numbers, decline reasons, or program ID. Missing conditional details often stops adjudication because the reviewer canât confirm coordination of benefits or required prerequisites. After any 'Yes' or 'No' that triggers a follow-up, immediately complete the related fields and attach the required documents. Instafill.ai can prompt for dependent fields and prevent submission when required follow-ups are missing.
This form repeatedly requires supporting documents in specific scenarios (e.g., proof of payment/Explanation of Benefits from prior insurer, other plan decline notice, Ontario EAP approval/denial). People often assume the form alone is enough, which leads to delays or an inability to assess the request. Carefully follow the instructions tied to your answers and include clear copies of the requested documents with the submission. If youâre using a digital workflow, Instafill.ai can help ensure the right attachments are included and remind you when documentation is required.
Because many questions are presented as separate Yes and No checkboxes, itâs common to accidentally check both or leave both unchecked. This creates contradictory information and typically results in manual follow-up or rejection as âincomplete.â For every Yes/No item, select exactly one option and review the page for duplicates before sending. Instafill.ai can detect mutually exclusive selections and prevent contradictory responses.
Prescribers or members often enter an incomplete dose (e.g., missing mg, concentration, or frequency) or fail to clearly indicate where treatment will be administered (Home vs MD Office vs hospital) and the facility details when not at home. Missing administration details can delay approval because the insurer may need them for clinical assessment and vendor/case management routing. Always include strength, dose, and frequency (e.g., â10 mg once weeklyâ) and complete facility name/address/phone when treatment is not at home. Instafill.ai can enforce required units and ensure the correct facility fields appear based on the selected location.
For renewals, the form asks for documented objective evidence of continued benefit (example: decreased HbA1c), but submissions often answer renewal questions as if they were initial requests or fail to provide/confirm objective benefit. This can lead to denial at renewal because the insurer cannot confirm ongoing clinical effectiveness. Confirm whether the request is initial or renewal and ensure the renewal section explicitly indicates objective evidence and aligns with the patientâs chart/labs. Instafill.ai can help by guiding users through the correct pathway and flagging missing renewal evidence fields.
A frequent issue is stating the patient has not achieved adequate glycemic control on metformin but not documenting intolerance/contraindication when required, or listing drug history that contradicts the criteria answers. Inconsistencies raise red flags and often trigger requests for clarification or denial due to unmet criteria. Ensure the clinical story is consistent: if metformin wasnât used or wasnât tolerated, document the intolerance/contraindication and reflect it in the drug history and rationale. Instafill.ai can cross-check related answers and highlight contradictions before submission.
In the drug history section, people often list drug names but omit start/end dates (in yyyy/mmm), fail to check the outcome (intolerance vs inadequate response), or forget to indicate whether the patient will continue the medication with the new therapy. Missing details make it difficult to assess prior therapy adequacy and can delay adjudication. Provide complete entries for each therapy: drug name, start date, end date (or leave blank if ongoing), outcome, and whether it will be continued. Instafill.ai can format the dates correctly and ensure each row is fully completed.
Submissions are commonly delayed because the plan member signature/date or the prescribing physician signature/date is missing, or the date is not in dd/mmm/yyyy format. Without proper authorization, Manulife may be unable to collect/verify information and may treat the request as incomplete. Before sending, confirm both signatures are present and dated correctly, and that the physician section is fully completed by the prescriber. If the form is only available as a flat non-fillable PDF in your workflow, Instafill.ai can convert it into a fillable version and reduce missed signature fields with completion checks.
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