Manulife Group Benefits Drug Prior Authorization Form (Ozempic/Semaglutide) – GL5197E Instructions

Enter the date the plan member signed this authorization and consent section.

Check this box if the drug is being prescribed for a diagnosis other than the Type 2 Diabetes Mellitus criteria options listed above.

Enter the specific diagnosis and summarize any Canadian clinical research supporting the use of this drug for the patient’s situation.

Enter the case manager’s first (given) name. Fill only if 'Yes' is 'Yes'.

Enter the case manager’s last (family) name. Fill only if 'Yes' is 'Yes'.

Enter the case manager’s phone number where they can be reached. Fill only if 'Yes' is 'Yes'.

Enter the case manager’s email address. Fill only if 'Yes' is 'Yes'.

Check this box if the patient has a confirmed diagnosis of type 2 diabetes mellitus.

Check this box if the patient does not have a confirmed diagnosis of type 2 diabetes mellitus.

Check this box if there is documented objective evidence of continued benefit for the patient, meaning the patient has a decrease in HbA1c. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'.

Check this box if there is no documented objective evidence of continued benefit for the patient (no decrease in HbA1c). Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'.

Check this box to indicate the prescription is for Type 2 Diabetes Mellitus and you are completing the Initial Criteria section.

Check this box if the prescribed Ozempic dose will exceed 2 mg once weekly. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'.

Check this box if the prescribed Ozempic dose will not exceed 2 mg once weekly. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'.

Enter the prescribed medication strength and the dosing instructions (amount per dose and how often it is to be taken or administered).

Check this box if the drug will be used as an adjunct to diet and exercise.

Check this box if the drug will not be used as an adjunct to diet and exercise.

Check this box if the prescribed drug will be used together with metformin.

Check this box if the prescribed drug will not be used together with metformin.

Check this box if the prescribed drug will be used in combination with metformin and a basal insulin.

Check this box if the prescribed drug will not be used in combination with metformin and a basal insulin.

Check this box if the drug will be used in combination with metformin and a sulfonylurea.

Check this box if the drug will not be used in combination with metformin and a sulfonylurea.

Check this box if the prescribed drug will be used in combination with metformin and a sodium-glucose cotransporter 2 inhibitor (SGLT2i).

Check this box if the prescribed drug will not be used in combination with metformin and an SGLT2 inhibitor (SGLT2i).

Check this box if the prescribed drug will be used in combination with other GLP-1 analog medications.

Check this box if the prescribed drug will not be used in combination with any other GLP-1 analog medications.

Enter the name of the fifth previous or current drug therapy used for the selected diagnosis.

Enter the date when the fifth drug therapy was started.

Enter the date when the fifth drug therapy was stopped or ended.

Check this box if the fifth drug therapy was stopped or considered unsuccessful due to intolerance, allergy, or another adverse event.

Check this box if the fifth drug therapy did not provide an adequate clinical response or resulted in a suboptimal response.

Check this box if the patient will continue this fifth drug therapy in addition to the new therapy.

Check this box if the patient will not continue this fifth drug therapy when starting the new therapy.

Enter the name of the first drug therapy previously or currently used for the selected diagnosis.

Enter the date when the patient started the first drug therapy.

Enter the date when the patient stopped the first drug therapy.

Check this box if the first drug therapy was stopped or could not be used due to intolerance, allergy, or another adverse event.

Check this box if the first drug therapy did not provide an adequate or optimal clinical response.

Check this box if the patient will continue this medication in addition to the new therapy.

Check this box if the patient will not continue this medication when starting the new therapy.

Enter the name of the fourth previous or current drug therapy used for the selected diagnosis.

Enter the date when the patient started the fourth drug therapy.

Enter the date when the patient ended the fourth drug therapy.

Check this box if the fourth drug therapy was stopped or not suitable due to intolerance, allergy, or an adverse event.

Check this box if the fourth drug therapy did not provide an adequate or optimal clinical response.

Check this box if the patient will continue the fourth drug therapy in addition to the new therapy.

Check this box if the patient will not continue the fourth drug therapy when starting the new therapy.

Check this box if the patient has achieved glycemic control with diet and exercise while on the maximal tolerated dose of metformin.

Check this box if the patient has not achieved glycemic control with diet and exercise despite the maximal tolerated dose of metformin.

Describe where the drug will be administered in the MD office or in another area of the hospital. Fill only if 'Yes' is 'Yes' (all).

Check this box if the patient has a documented intolerance or contraindication to metformin (when metformin is not being used). Fill only if 'No' is 'Yes'.

Check this box if the patient does not have a documented intolerance or contraindication to metformin (when metformin is not being used). Fill only if 'No' is 'Yes'.

Check this box if the patient has an intolerance or contraindication to metformin.

Check this box if the patient does not have an intolerance or contraindication to metformin.

Check this box if the prescribing physician’s office is located in a hospital. Fill only if 'MD office' is 'Yes' (all).

Check this box if the prescribing physician’s office is not located in a hospital. Fill only if 'MD office' is 'Yes' (all).

Provide the medical rationale explaining why no previous therapies have been tried for the selected diagnosis. Fill only if 'Risk of drug interaction', 'Patient has contraindication', 'Other' any is 'Yes'.

Check this box if no previous therapies were tried because they pose a risk of drug interaction for the patient.

Check this box if no previous therapies were tried because the patient has a contraindication to those therapies.

Check this box if no previous therapies were tried for a reason other than drug interaction risk or contraindication, and specify the rationale in the space provided.

Enter the name of the private clinic or hospital where the treatment will be administered. Fill only if 'Home' is 'No' (all).

Enter the telephone number for the clinic or hospital where the treatment will be administered. Fill only if 'Home' is 'No' (all).

Enter the facility’s street address including the street number and street name. Fill only if 'Home' is 'No' (all).

Enter the suite, unit, or room number for the facility address, if applicable. Fill only if 'Home' is 'No' (all).

Enter the city or town where the facility is located. Fill only if 'Home' is 'No' (all).

Enter the province where the facility is located. Fill only if 'Home' is 'No' (all).

Enter the postal code for the facility address. Fill only if 'Home' is 'No' (all).

Check this box if the patient has drug coverage under another group plan.

Check this box if the patient does not have drug coverage under any other group plan.

Check this box if this drug is covered under the patient’s other group plan. Fill only if 'Other group plan drug coverage: Yes' is 'Yes'.

Check this box if this drug is not covered under the patient’s other group plan. Fill only if 'Other group plan drug coverage: Yes' is 'Yes'.

Enter the name of the other group plan insurance company providing the patient’s drug coverage. Fill only if 'Other group plan drug coverage: Yes' is 'Yes'.

Enter the contract number for the patient’s other group plan insurance. Fill only if 'Other group plan drug coverage: Yes' is 'Yes'.

Enter the plan member’s certificate number for the other group plan insurance. Fill only if 'Other group plan drug coverage: Yes' is 'Yes'.

Check this box if the prescribed Ozempic dose will exceed 2 mg once weekly.

Check this box if the prescribed Ozempic dose will not exceed 2 mg once weekly.

Enter the name of the patient assistance program the patient is enrolled in for the requested drug. Fill only if 'Yes' is 'Yes'.

Enter the patient’s identification or membership number for the patient assistance program. Fill only if 'Yes' is 'Yes'.

Check this box if the patient has enrolled in a Patient Assistance Program for the requested drug.

Check this box if the patient has not enrolled in a Patient Assistance Program for the requested drug.

Enter the patient’s preferred daytime phone number where they can be reached.

Enter the patient’s email address, if available, for contact and notifications.

Enter the patient's first name.

Enter the patient's middle initial (if applicable).

Enter the patient's last name (surname).

Enter the patient's date of birth.

Enter the patient's relationship to the plan member (e.g., self, spouse, child).

Enter the date the prescribing physician signed the authorization statement.

Enter the plan contract number for the drug benefit plan under which coverage is being requested.

Enter the plan member’s certificate number as shown on the benefits card or plan documents.

Enter the name of the plan sponsor (typically the employer or organization providing the benefits plan).

Enter the plan member’s street address including the civic number and street name.

Enter the plan member’s apartment, unit, or suite number (if applicable).

Enter the city or town for the plan member’s address.

Enter the province for the plan member’s address.

Enter the postal code for the plan member’s address.

Enter the plan member’s first (given) name.

Enter the plan member’s middle initial, if applicable.

Enter the plan member’s last (family) name.

Enter the plan member’s date of birth.

Enter the prescribing physician’s street address including the civic/street number and street name.

Enter the prescribing physician’s suite, unit, or office number (if applicable).

Enter the city or town for the prescribing physician’s address.

Enter the province for the prescribing physician’s address.

Enter the postal code for the prescribing physician’s address.

Enter the prescribing physician’s main telephone number.

Enter the extension number for the prescribing physician’s telephone line, if applicable.

Enter the fax number for the prescribing physician’s office.

Enter the prescribing physician’s first name.

Enter the prescribing physician’s last name.

Enter the prescribing physician’s professional college or medical license number.

Enter the prescribing physician’s medical specialty.

Check this box if an application has been made to the provincial program for coverage.

Check this box if an application has not been made to the provincial program for coverage.

Enter the reason the patient has not applied to the applicable provincial program for coverage, if no application has been made. Fill only if 'No' is 'Yes'.

Check this box if the patient has been approved for coverage by the provincial program for this drug.

Check this box if the patient has not been approved for coverage by the provincial program for this drug.

Enter an explanation of why the provincial program did not approve coverage for this drug, if applicable. Fill only if 'No' is 'Yes'.

Check this box if your plan sponsor recently transferred your drug benefits to Manulife.

Check this box if your plan sponsor did not recently transfer your drug benefits to Manulife.

Check this box if, before joining Manulife, you were receiving coverage for this drug through your previous insurance company.

Check this box if, before joining Manulife, you were not receiving coverage for this drug through your previous insurance company.

Enter the name of the second previous or current drug therapy used for the selected diagnosis.

Enter the date the patient started the second drug therapy.

Enter the date the patient stopped the second drug therapy, if applicable.

Check this box if the second listed drug therapy was stopped or not tolerated due to an allergy or other adverse event.

Check this box if the second listed drug therapy resulted in an inadequate or suboptimal clinical response.

Check this box if the patient will continue the second listed medication in addition to the new therapy.

Check this box if the patient will not continue the second listed medication when starting the new therapy.

Enter the name of the third previous or current drug therapy used for the selected diagnosis.

Enter the date when the patient started the third drug therapy.

Enter the date when the patient stopped the third drug therapy.

Check this box if the third drug therapy was stopped or not suitable due to intolerance, allergy, or an adverse event.

Check this box if the third drug therapy did not provide an adequate or optimal clinical response.

Check this box if the patient will continue the third drug therapy in addition to the new therapy.

Check this box if the patient will not continue the third drug therapy when starting the new therapy.

Check this box if the treatment will be administered at the patient’s home.

Check this box if the treatment will be administered in the prescribing physician’s (MD) office.

Check this box if the treatment will be administered at a private clinic.

Check this box if the treatment will be administered during an inpatient hospital stay.

Check this box if the treatment will be administered at a hospital on an outpatient basis.

Check this box to indicate the request is for renewal under the Type 2 Diabetes Mellitus renewal criteria section. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'.

Check this box if the drug is being used in combination with metformin. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'.

Check this box if the drug is not being used in combination with metformin. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'.

Check this box if Ozempic will be given in combination with other GLP-1 analogs. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'.

Check this box if Ozempic will not be given in combination with other GLP-1 analogs. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'.