This form contains 111 fields organized into 22 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Any other diagnosis
Any other diagnosis	Checkbox	Check this box if the patient has a diagnosis not listed elsewhere on the form and you will provide the specific diagnosis and any supporting Canadian clinical research in the text area below.
Any other diagnosis — specific diagnosis and supporting evidence	Text	Enter the specific diagnosis being treated and provide concise Canadian clinical research or evidence that supports the use of this drug in the patient’s context.
Drug strength and dosage
Drug strength and dosage	Text	Enter the medication’s strength and dosage as used for this prescription, including units (for example “50 mg”, “2 mg/mL”) and any dose frequency or amount if required.
First Drug therapy entry
First drug name	Text	Enter the name of the first drug previously or currently used to treat the selected diagnosis.
First drug start date	Date	Enter the date when the first drug therapy was started for this diagnosis.
First drug end date	Date	Enter the date when the first drug therapy was stopped or the therapy end date if still ongoing. Fill only if 'First drug therapy — No (patient will not continue medication)' is 'Yes'. Depends on: First drug therapy — No (patient will not continue medication)
First drug therapy — Intolerance (Allergy/Adverse Event)	Checkbox	Check this box when the outcome of the first listed drug was intolerance, such as an allergy or other adverse event that affected treatment.
First drug therapy — Inadequate/Suboptimal Response	Checkbox	Check this box when the first listed drug produced an inadequate or suboptimal clinical response.
First drug therapy — Yes (patient will continue medication)	Checkbox	Check this box if the patient will continue taking this medication in addition to the new therapy.
First drug therapy — No (patient will not continue medication)	Checkbox	Check this box if the patient will not continue this medication when the new therapy is started.
Initial Criteria
Initial Criteria	Checkbox	Check this box to indicate you are completing or selecting the Initial Criteria section for this diagnosis.
Does patient have a confirmed diagnosis of type 2 diabetes mellitus? — Yes	Checkbox	Check this box if the patient has a confirmed diagnosis of type 2 diabetes mellitus.
Does patient have a confirmed diagnosis of type 2 diabetes mellitus? — No	Checkbox	Check this box if the patient does not have a confirmed diagnosis of type 2 diabetes mellitus.
Has patient achieved adequate glycemic control with the maximum tolerated dose of metformin and diet and exercise? — Yes	Checkbox	Check this box if the patient has achieved adequate glycemic control using the maximum tolerated dose of metformin together with diet and exercise.
Has patient achieved adequate glycemic control with the maximum tolerated dose of metformin and diet and exercise? — No	Checkbox	Check this box if the patient has not achieved adequate glycemic control despite the maximum tolerated dose of metformin and diet and exercise.
Will Mounjaro be used as an adjunct to diet and exercise? — Yes	Checkbox	Check this box if Mounjaro will be prescribed as an adjunct to the patient’s diet and exercise regimen.
Will Mounjaro be used as an adjunct to diet and exercise? — No	Checkbox	Check this box if Mounjaro will not be used as an adjunct to diet and exercise.
Drugs to be taken in combination with Mounjaro	Text	Enter the names of all medications the patient will take in combination with Mounjaro, listing each drug (include brand or generic name and, if known, dose and frequency) separated by commas. Fill only if 'Will Mounjaro be given in combination with other GLP-1 analogs? — Yes', 'Will Mounjaro be given in combination with other GLP-1 analogs? (Yes)' Will Mounjaro be given in combination with other GLP-1 analogs? is 'Yes' (any). Depends on: Will Mounjaro be given in combination with other GLP-1 analogs? — Yes, Will Mounjaro be given in combination with other GLP-1 analogs? (Yes)
Does patient have documented intolerance or contraindication to metformin? — Yes	Checkbox	Check this box if the patient has a documented intolerance or contraindication to metformin. Fill only if 'Has patient achieved adequate glycemic control with the maximum tolerated dose of metformin and diet and exercise? — No' Has patient achieved adequate glycemic control with the maximum tolerated dose of metformin and diet and exercise? is 'No'. Depends on: Has patient achieved adequate glycemic control with the maximum tolerated dose of metformin and diet and exercise? — No
Does patient have documented intolerance or contraindication to metformin? — No	Checkbox	Check this box if the patient does not have a documented intolerance or contraindication to metformin. Fill only if 'Has patient achieved adequate glycemic control with the maximum tolerated dose of metformin and diet and exercise? — No' Has patient achieved adequate glycemic control with the maximum tolerated dose of metformin and diet and exercise? is 'No'. Depends on: Has patient achieved adequate glycemic control with the maximum tolerated dose of metformin and diet and exercise? — No
Will dose of Mounjaro exceed 15 mg once weekly? — Yes	Checkbox	Check this box if the planned dose of Mounjaro will exceed 15 mg once weekly.
Will dose of Mounjaro exceed 15 mg once weekly? — No	Checkbox	Check this box if the planned dose of Mounjaro will not exceed 15 mg once weekly.
Will Mounjaro be given in combination with other GLP-1 analogs? — Yes	Checkbox	Check this box if Mounjaro will be administered in combination with other GLP-1 analog medications.
Will Mounjaro be given in combination with other GLP-1 analogs? — No	Checkbox	Check this box if Mounjaro will not be given together with other GLP-1 analogs.
MD office / hospital administration details
Is the MD office located in a hospital? — Yes	Checkbox	Check this box if the prescribing physician's MD office is located within a hospital. Fill only if 'MD Office' is 'Yes'. Depends on: MD Office
Is the MD office located in a hospital? — No	Checkbox	Check this box if the prescribing physician's MD office is not located within a hospital. Fill only if 'MD Office' is 'Yes'. Depends on: MD Office
MD office / hospital administration details	Text	Describe where the drug will be administered — indicate whether it will be given in the MD office or elsewhere in the hospital and provide any specific location or procedural details needed for administration. Fill only if 'Is the MD office located in a hospital? — Yes' is 'Yes'. Depends on: Is the MD office located in a hospital? — Yes
Non-home treatment facility contact and address
Facility name	Text	Enter the full name of the private clinic or hospital where the treatment will be administered. Fill only if 'Home' is 'No'. Depends on: Home
Facility telephone number	Text	Enter the main telephone number for the facility, including area code and any extension if applicable. Fill only if 'Home' is 'No'. Max length: 10 characters Depends on: Home
Facility street address	Text	Provide the facility's street address, including building number, street name and apartment or suite number if applicable. Fill only if 'Home' is 'No'. Depends on: Home
Facility city or town	Text	Enter the city or town in which the facility is located. Fill only if 'Home' is 'No'. Depends on: Home
Facility province	Combobox	Enter the province (or state) where the facility is located. Fill only if 'Home' is 'No'. PE AB NS QC NU NB NL YT SK NT MB BC ON Depends on: Home
Facility postal code	Text	Enter the facility's postal code or ZIP code. Fill only if 'Home' is 'No'. Depends on: Home
Other group plan - coverage yes/no
Other group plan - Yes	Checkbox	Check this box if the patient does have drug coverage under any other group plan.
Other group plan - No	Checkbox	Check this box if the patient does not have drug coverage under any other group plan.
Other group plan - insurer and plan details
Other plan — Insurance company name	Text	Enter the full name of the other insurance company that provides the patient’s drug coverage under a different group plan. Fill only if 'Other group plan - Yes' is 'Yes'. Depends on: Other group plan - Yes
Other plan — Plan contract number	Text	Enter the contract number assigned to the other group plan as shown on the patient’s other insurance documents. Fill only if 'Other group plan - Yes' is 'Yes'. Depends on: Other group plan - Yes
Other plan — Plan member certificate number	Text	Enter the plan member’s certificate or ID number for the other group plan as it appears on the member’s insurance card or paperwork. Fill only if 'Other group plan - Yes' is 'Yes'. Depends on: Other group plan - Yes
Is this drug covered under the other group plan — Yes	Checkbox	Check this box when the drug IS covered under the other group plan identified in the insurer/plan details. Fill only if 'Other group plan - Yes' is 'Yes'. Depends on: Other group plan - Yes
Is this drug covered under the other group plan — No	Checkbox	Check this box when the drug IS NOT covered under the other group plan identified in the insurer/plan details. Fill only if 'Other group plan - Yes' is 'Yes'. Depends on: Other group plan - Yes
Patient Assistance Program enrollment and details
Enrolled in Patient Assistance Program — Yes	Checkbox	Check this box if the patient/plan member has enrolled in the Patient Assistance Program.
Enrolled in Patient Assistance Program — No	Checkbox	Check this box if the patient/plan member has not enrolled in the Patient Assistance Program.
Patient Assistance Program ID Number	Text	Enter the Patient Assistance Program identification number you were assigned (include any letters or dashes exactly as shown). Fill only if 'Enrolled in Patient Assistance Program — Yes' is 'Yes'. Depends on: Enrolled in Patient Assistance Program — Yes
Case Manager Name and Contact Details	Text	Provide the full name of the case manager and their contact details (phone number, email and/or address) so they can be contacted about this patient’s enrollment. Fill only if 'Enrolled in Patient Assistance Program — Yes' is 'Yes'. Depends on: Enrolled in Patient Assistance Program — Yes
Patient personal and contact information
Patient full name	Text	Enter the patient's full name including first name, middle initial (if any) and last name.
Patient date of birth	Date	Enter the patient's date of birth.
Relationship to plan member	Text	Specify the patient's relationship to the plan member (for example: self, spouse, child, dependent).
Patient preferred daytime phone number	Text	Enter the patient's primary daytime phone number including area code so they can be contacted. Max length: 10 characters
Phone extension (if applicable)	Text	Enter the phone extension or additional dialing digits for the daytime number if applicable, otherwise leave blank. Max length: 6 characters
Patient email address (optional)	Text	Provide the patient's email address for contact purposes, or leave blank if none.
Plan identifiers (contract, member certificate, sponsor)
Plan contract number	Text	Enter the plan contract number assigned by the insurer for the member's group benefits plan (provide any letters or digits exactly as shown on plan documents).
Plan member certificate number	Text	Enter the member certificate or ID number that identifies the individual covered under the group plan (include any leading zeros or letters).
Plan sponsor	Text	Enter the name of the plan sponsor or employer that provides the group benefits plan as shown on the member's coverage information.
Plan member personal and address information
Plan member name	Text	Enter the plan member's full name, including first name, middle initial (if any) and last name.
Plan member date of birth	Date	Enter the plan member's date of birth.
Plan member address	Text	Enter the plan member's street address including building number, street name and apartment or unit number if applicable.
City or town	Text	Enter the city or town of the plan member's mailing address.
Province	Combobox	Enter the province (or state) of the plan member's mailing address. PE AB NS QC NU NB NL YT SK NT MB BC ON
Postal code	Text	Enter the postal or ZIP code for the plan member's address.
Plan sponsor transfer and prior coverage questions
Plan sponsor recently transferred benefits — Yes	Checkbox	Check this box if your plan sponsor recently transferred your drug benefits to Manulife.
Plan sponsor recently transferred benefits — No	Checkbox	Check this box if your plan sponsor did not recently transfer your drug benefits to Manulife.
Previously receiving coverage for this drug — Yes	Checkbox	Check this box if, before joining Manulife, you were receiving coverage for this drug through your previous insurance company.
Previously receiving coverage for this drug — No	Checkbox	Check this box if, before joining Manulife, you were not receiving coverage for this drug through your previous insurance company.
Prescribing physician information
Prescribing physician's name	Text	Enter the prescribing physician's full name (given name and surname) as it should appear on the record.
Specialty	Text	Enter the prescriber's medical specialty or area of practice (for example, Cardiology or Dermatology).
Address (number, street and suite)	Text	Enter the physician's office street address including building number, street name, and suite or unit number if applicable.
City or town	Text	Enter the city or town where the physician's office is located.
Province	Combobox	Enter the province or state in which the physician's office is located. PE AB NS QC NU NB NL YT SK NT MB BC ON
Postal code	Text	Enter the office postal code or ZIP code for the physician's mailing address.
Telephone number	Text	Enter the physician's primary office telephone number including area code. Max length: 10 characters
Extension	Text	Enter the telephone extension for the physician or office contact if applicable, or leave blank if none. Max length: 6 characters
Fax number	Text	Enter the office fax number including area code if available. Max length: 10 characters
Previous therapies rationale
Risk of drug interaction	Checkbox	Check this box if no previous therapies were tried because of a clinically relevant risk of drug–drug interaction that contraindicated those therapies.
Patient has contraindication	Checkbox	Check this box if no previous therapies were tried because the patient has a contraindication to those therapies.
Other	Checkbox	Check this box if no previous therapies were tried for a reason not listed above, and provide the specific medical rationale in the space provided.
Medical rationale for previous therapies	Text	Enter a concise medical explanation describing the clinical rationale for prior or no previous therapies for the selected diagnosis (for example reasons why treatments were not tried, contraindications, or other relevant clinical justification). Fill only if 'Risk of drug interaction', 'Patient has contraindication', 'Other' is 'Yes' any. Depends on: Risk of drug interaction, Patient has contraindication, Other
Provincial application - Approved for coverage?
Has the patient been approved for coverage by the provincial program for this drug? – Yes	Checkbox	Check this box when the patient has been approved for coverage by the provincial program for the prescribed drug. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company?' is 'No'. Depends on: Previously receiving coverage for this drug — No
Has the patient been approved for coverage by the provincial program for this drug? – No	Checkbox	Check this box when the patient has not been approved for coverage by the provincial program for the prescribed drug. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company?' is 'No'. Depends on: Previously receiving coverage for this drug — No
Reason provincial coverage was declined	Text	Enter the reason or details provided by the provincial program explaining why the patient's application for coverage of this drug was declined. Fill only if 'Has the patient been approved for coverage by the provincial program for this drug? – No' is 'No'. Depends on: Has the patient been approved for coverage by the provincial program for this drug? – No
Provincial application - Has application been made?
Has application been made to the provincial program for coverage? — Yes	Checkbox	Check this box if an application has already been submitted to the provincial program for coverage of this drug. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company?' is 'No'. Depends on: Previously receiving coverage for this drug — No
Has application been made to the provincial program for coverage? — No	Checkbox	Check this box if no application has been submitted to the provincial program for coverage of this drug (and provide the reason in the 'If no, why?' field). Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company?' is 'No'. Depends on: Previously receiving coverage for this drug — No
Reason application not made	Text	Enter a brief explanation stating why an application has not been made to the provincial program for coverage of this drug. Fill only if 'Has application been made to the provincial program for coverage? — No' is 'No'. Depends on: Has application been made to the provincial program for coverage? — No
Renewal Criteria
d1.chk1_Renewal#20Criteria	CheckBox
Is there documented objective evidence of continued benefit (Yes)	Checkbox	Check this box if there is documented objective evidence that the patient has continued benefit from treatment (for example, a decrease in HbA1c).
Is there documented objective evidence of continued benefit (No)	Checkbox	Check this box if there is no documented objective evidence that the patient has continued benefit from treatment (for example, no decrease in HbA1c).
Will Mounjaro be used as an adjunct to diet and exercise? (Yes)	Checkbox	Check this box if Mounjaro will be used as an adjunct to diet and exercise for this patient.
Will Mounjaro be used as an adjunct to diet and exercise? (No)	Checkbox	Check this box if Mounjaro will not be used as an adjunct to diet and exercise for this patient.
Will Mounjaro be given in combination with other GLP-1 analogs? (Yes)	Checkbox	Check this box if Mounjaro will be given in combination with other GLP‑1 analog medications.
Will Mounjaro be given in combination with other GLP-1 analogs? (No)	Checkbox	Check this box if Mounjaro will not be given in combination with other GLP‑1 analog medications.
Will dose of Mounjaro exceed 15 mg once weekly? (Yes)	Checkbox	Check this box if the planned dose of Mounjaro will exceed 15 mg once weekly.
Will dose of Mounjaro exceed 15 mg once weekly? (No)	Checkbox	Check this box if the planned dose of Mounjaro will not exceed 15 mg once weekly.
Second Drug therapy entry
Second therapy - Drug name	Text	Enter the full name of the previous or current medication used for the second drug therapy entry.
Second therapy - Start date	Date	Enter the date when the patient began this medication for the second drug therapy entry.
Second therapy - End date	Date	Enter the date when the patient stopped this medication for the second drug therapy entry (or leave blank if ongoing). Fill only if 'Second drug therapy: Continuing on medication — No' is 'Yes'. Depends on: Second drug therapy: Continuing on medication — No
Second drug therapy: Intolerance (Allergy/Adverse Event)	Checkbox	Check this box if the outcome for the second listed drug was intolerance (an allergy or adverse event).
Second drug therapy: Inadequate/Suboptimal Response	Checkbox	Check this box if the outcome for the second listed drug was an inadequate or suboptimal response.
Second drug therapy: Continuing on medication — Yes	Checkbox	Check this box if the patient will continue the second listed medication in addition to the new therapy.
Second drug therapy: Continuing on medication — No	Checkbox	Check this box if the patient will not continue the second listed medication in addition to the new therapy.
Third Drug therapy entry
Third drug name	Text	Enter the name of the third drug therapy previously or currently used for the selected diagnosis.
Third drug start date	Date	Enter the start date when the third drug therapy was initiated.
Third drug end date	Date	Enter the end date when the third drug therapy was stopped, or leave blank if ongoing. Fill only if 'Third drug therapy - Continuing on medication: No' is 'Yes'. Depends on: Third drug therapy - Continuing on medication: No
Third drug therapy - Intolerance (Allergy/Adverse Event)	Checkbox	Check this box if the outcome for the third listed drug was intolerance, such as an allergy or other adverse event.
Third drug therapy - Inadequate/Suboptimal Response	Checkbox	Check this box if the outcome for the third listed drug was an inadequate or suboptimal therapeutic response.
Third drug therapy - Continuing on medication: Yes	Checkbox	Check this box if the patient will continue taking the third listed medication in addition to the new therapy.
Third drug therapy - Continuing on medication: No	Checkbox	Check this box if the patient will not continue taking the third listed medication in addition to the new therapy.
Treatment administration location (options)
Home	Checkbox	Check this box if the treatment will be administered at the patient's home (for example, by a visiting nurse or home infusion).
MD Office	Checkbox	Check this box if the treatment will be administered in the medical doctor's (MD) office or the prescribing physician's office.
Private Clinic	Checkbox	Check this box if the treatment will be administered at a private clinic or non-hospital outpatient facility.
Hospital/In-patient	Checkbox	Check this box if the patient will receive the treatment while admitted as an in-patient in a hospital (overnight stay).
Hospital/Out-patient	Checkbox	Check this box if the treatment will be provided at a hospital on an outpatient basis (no overnight admission).
Type 2 Diabetes Mellitus (section header)
1 Type 2 Diabetes Mellitus	Checkbox	Check this box when the drug is being prescribed for a diagnosis of Type 2 Diabetes Mellitus (select this diagnosis to reveal/respond to the related questions).

Manulife Group Benefits Drug Prior Authorization Form – Mounjaro (Tirzepatide) (GL5197E) Instructions