This form contains 191 fields organized into 60 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
7 – Authorization and Plan member signature
Date signed	Date	Enter the date on which the plan member signed the authorization and consent section.
Adequate Response to Diet and Physical Activity Alone (Yes/No)
Yes	Radiobutton	Check this box if the patient had an adequate response to a reduced-calorie diet and physical activity alone.
No	Radiobutton	Check this box if the patient did not have an adequate response to a reduced-calorie diet and physical activity alone.
Adjunctive Use With Reduced Calorie Diet and Increased Physical Activity (Yes/No)
Yes	Radiobutton	Check this box if the drug will be used adjunctive to a reduced calorie diet and increased physical activity.
No	Radiobutton	Check this box if the drug will not be used adjunctive to a reduced calorie diet and increased physical activity.
Any Other Diagnosis
Any Other Diagnosis	Checkbox	Check this box if the patient has an additional diagnosis not otherwise listed and you will provide the specific diagnosis and supporting Canadian clinical research.
Other Diagnosis Details and Supporting Research	Text	Enter the specific other diagnosis and summarize any Canadian clinical research supporting use of the drug in the patient’s context.
Baseline Measurements
Baseline Body Weight	Number	Enter the patient’s baseline body weight at the start of treatment.
Baseline Body Mass Index (BMI)	Number	Enter the patient’s baseline body mass index (BMI) at the start of treatment.
BMI at or Above 95th Percentile (Yes/No)
Yes	Radiobutton	Check this box if the patient’s initial BMI is at or above the 95th percentile for age.
No	Radiobutton	Check this box if the patient’s initial BMI is below the 95th percentile for age.
Case Manager Contact Information
Case Manager First Name	Text	Enter the case manager's first name. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Case Manager Last Name	Text	Enter the case manager's last name. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Case Manager Phone Number	Text	Enter the case manager's phone number. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Case Manager Email Address	Text	Enter the case manager's email address. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Chronic Weight Management (adult) - Renewal Criteria Section
Chronic Weight Management (adult) - Renewal Criteria	Radiobutton	Check this box to indicate you are completing the Chronic Weight Management (adult) renewal criteria section for this request. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
Current Baseline Body Mass Index (BMI)
Current Baseline BMI	Number	Enter the patient’s current baseline body mass index (BMI) for this renewal assessment. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
Current Baseline BMI	Number	Enter the patient’s current baseline body mass index (BMI).
Diagnosis Selection - Chronic Weight Management (Pediatric) Initial Criteria
Chronic Weight Management (pediatric) – Initial Criteria	Radiobutton	Check this box if the prescribed drug is being requested for chronic weight management in a pediatric patient under the initial criteria pathway.
Does drug continue to provide benefit to the patient?
Yes	Radiobutton	Check this box if the drug continues to provide benefit to the patient. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
No	Radiobutton	Check this box if the drug does not continue to provide benefit to the patient. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
Drug Administration Area Description
Drug Administration Area Description	Text	Describe where the drug will be administered (e.g., in the MD office or another specific area of the hospital). Fill only if 'MD office', 'Yes' is 'Yes' (all). Depends on: MD office, Yes
Drug Covered Under Other Group Plan (Yes/No)
Yes	Radiobutton	Check this box if the requested drug is covered under the patient’s other group plan. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if the requested drug is not covered under the patient’s other group plan. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Drug Strength and Dosage
Drug Strength and Dosage	Text	Enter the prescribed medication strength and the dosage instructions, including the amount per dose and how often it should be taken or administered.
Established Cardiovascular Disease Evidence (Check All That Apply)
Prior myocardial infarction	Checkbox	Check this box if the patient has a history of a myocardial infarction (heart attack).
Prior ischemic or hemorrhagic stroke	Checkbox	Check this box if the patient has previously had an ischemic stroke or a hemorrhagic stroke.
Symptomatic peripheral artery disease	Checkbox	Check this box if the patient has symptomatic peripheral artery disease (e.g., intermittent claudication with ankle-brachial index < 0.85 at rest, prior peripheral arterial revascularization, or amputation due to atherosclerotic disease).
Fifth Drug Therapy Row
Drug name (Row 5)	Text	Enter the name of the fifth previous or current drug therapy used for the selected diagnosis.
Start date (Row 5)	Date	Enter the date when the fifth listed drug therapy was started.
End date (Row 5)	Date	Enter the date when the fifth listed drug therapy ended.
Intolerance (Allergy/Adverse Event)	Radiobutton	Check this box if the fifth listed drug therapy was stopped or considered unsuccessful due to intolerance, allergy, or an adverse event.
Inadequate/Suboptimal Response	Radiobutton	Check this box if the fifth listed drug therapy resulted in an inadequate or suboptimal clinical response.
Yes	Radiobutton	Check this box if the patient will continue the fifth listed medication in addition to the new therapy.
No	Radiobutton	Check this box if the patient will not continue the fifth listed medication when starting the new therapy.
First Drug Therapy Row
Drug Name (Row 1)	Text	Enter the name of the previous or current drug therapy for the first row.
Start Date (Row 1)	Date	Enter the start date for the first listed drug therapy.
End Date (Row 1)	Date	Enter the end date for the first listed drug therapy.
Intolerance (Allergy/Adverse Event)	Radiobutton	Check this box if the listed drug therapy was stopped or not suitable due to intolerance, allergy, or an adverse event.
Inadequate/Suboptimal Response	Radiobutton	Check this box if the listed drug therapy produced an inadequate or suboptimal clinical response.
Continuing this medication with new therapy: Yes	Radiobutton	Check this box if the patient will continue taking this medication in addition to the new therapy.
Continuing this medication with new therapy: No	Radiobutton	Check this box if the patient will not continue taking this medication when starting the new therapy.
Fourth Drug Therapy Row
Drug Name (Therapy 4)	Text	Enter the name of the fourth previous or current drug therapy for the selected diagnosis.
Start Date (Therapy 4)	Date	Enter the date when the fourth drug therapy was started.
End Date (Therapy 4)	Date	Enter the date when the fourth drug therapy ended.
Intolerance (Allergy/Adverse Event)	Radiobutton	Check this box if the outcome of this (fourth) drug therapy was intolerance, such as an allergy or other adverse event.
Inadequate/Suboptimal Response	Radiobutton	Check this box if the outcome of this (fourth) drug therapy was an inadequate or suboptimal clinical response.
Continuing medication with new therapy — Yes	Radiobutton	Check this box if the patient will continue this (fourth) medication in addition to the new therapy.
Continuing medication with new therapy — No	Radiobutton	Check this box if the patient will not continue this (fourth) medication when starting the new therapy.
General
PhysicianSignature	Signature
PlanmemberSignature	Signature
Has patient lost at least 5% of baseline body weight?
Yes	Radiobutton	Check this box if the patient has lost at least 5% of their baseline body weight. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
No	Radiobutton	Check this box if the patient has not lost at least 5% of their baseline body weight. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
Has patient's BMI improved?
Yes	Radiobutton	Check this box if the patient’s BMI has improved since the baseline measurement. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
No	Radiobutton	Check this box if the patient’s BMI has not improved since the baseline measurement. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
Initial Criteria - Baseline Measurements
Baseline Body Weight	Number	Enter the patient’s baseline body weight at the start of treatment evaluation.
Baseline Body Mass Index (BMI)	Number	Enter the patient’s baseline body mass index (BMI) at the start of treatment evaluation.
Initial Criteria - Eligibility Questions (Yes/No)
BMI ≥ 30 kg/m² (Yes)	Radiobutton	Check this box if the patient’s initial body mass index (BMI) is 30 kg/m² or higher.
BMI ≥ 30 kg/m² (No)	Radiobutton	Check this box if the patient’s initial body mass index (BMI) is less than 30 kg/m².
Used as adjunct to reduced-calorie diet and increased physical activity (Yes)	Radiobutton	Check this box if the drug will be used together with a reduced-calorie diet and increased physical activity.
Used as adjunct to reduced-calorie diet and increased physical activity (No)	Radiobutton	Check this box if the drug will not be used together with a reduced-calorie diet and increased physical activity.
Used in combination with other GLP-1 analogs (Yes)	Radiobutton	Check this box if the drug will be used in combination with other GLP-1 analog medications.
Used in combination with other GLP-1 analogs (No)	Radiobutton	Check this box if the drug will not be used in combination with other GLP-1 analog medications.
Wegovy dose exceeds 2.4 mg once weekly (Yes)	Radiobutton	Check this box if the planned Wegovy dose will exceed 2.4 mg once weekly.
Wegovy dose exceeds 2.4 mg once weekly (No)	Radiobutton	Check this box if the planned Wegovy dose will not exceed 2.4 mg once weekly.
Weight-related comorbid condition present (Yes)	Radiobutton	Check this box if the patient has a weight-related comorbid condition.
Weight-related comorbid condition present (No)	Radiobutton	Check this box if the patient does not have a weight-related comorbid condition.
Initial Criteria - Weight-Related Comorbid Conditions
Hypertension	Checkbox	Check this box if the patient has hypertension as a weight-related comorbid condition. Fill only if 'Weight-related comorbid condition present (Yes)' is 'Yes'. Depends on: Weight-related comorbid condition present (Yes)
Type 2 diabetes mellitus	Checkbox	Check this box if the patient has type 2 diabetes mellitus as a weight-related comorbid condition. Fill only if 'Weight-related comorbid condition present (Yes)' is 'Yes'. Depends on: Weight-related comorbid condition present (Yes)
Dyslipidemia	Checkbox	Check this box if the patient has dyslipidemia as a weight-related comorbid condition. Fill only if 'Weight-related comorbid condition present (Yes)' is 'Yes'. Depends on: Weight-related comorbid condition present (Yes)
Obstructive sleep apnea	Checkbox	Check this box if the patient has obstructive sleep apnea as a weight-related comorbid condition. Fill only if 'Weight-related comorbid condition present (Yes)' is 'Yes'. Depends on: Weight-related comorbid condition present (Yes)
Other	Checkbox	Check this box if the patient has another weight-related comorbid condition not listed (and specify it in the space provided). Fill only if 'Weight-related comorbid condition present (Yes)' is 'Yes'. Depends on: Weight-related comorbid condition present (Yes)
Other Weight-Related Comorbid Condition	Text	Enter the name of any other weight-related comorbid condition the patient has that is not listed above. Fill only if 'Other' is 'Yes'. Depends on: Other
Initial Criteria Section Selection
Chronic Weight Management (adult) – Initial Criteria	Radiobutton	Check this box when the request is being submitted under the Adult Chronic Weight Management initial criteria section.
Non-fatal Myocardial Infarction Risk Reduction (Overweight/Obese Adults) – Initial Criteria	Radiobutton	Check this box when completing the initial-criteria section for Non-fatal Myocardial Infarction risk reduction in overweight and obese adults.
MD Office Located in a Hospital (Yes/No)
Yes	Radiobutton	Check this box if the prescribing MD’s office is located within a hospital.
No	Radiobutton	Check this box if the prescribing MD’s office is not located within a hospital.
No Diabetes/HbA1c Exclusion Confirmation
Patient does not have HbA1c ≥ 6.5% or history of type 1 or type 2 diabetes	Checkbox	Check this box to confirm the patient has neither an HbA1c of 6.5% or greater nor a history of type 1 or type 2 diabetes.
No Previous Therapies Rationale
Risk of drug interaction	Radiobutton	Check this box if no previous therapies were tried because they pose a risk of drug interaction.
Patient has contraindication	Radiobutton	Check this box if no previous therapies were tried because the patient has a contraindication to them.
Other	Radiobutton	Check this box if no previous therapies were tried for a reason not listed and you will provide the medical rationale.
Medical rationale for no previous therapies	Text	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' is selected (any). Depends on: Risk of drug interaction, Patient has contraindication, Other
Non-fatal Myocardial Infarction Risk Reduction Renewal Criteria Section
Non-fatal Myocardial Infarction Risk Reduction in Overweight and Obese Adults – Renewal Criteria	Radiobutton	Check this box to indicate you are completing the renewal criteria section for non-fatal myocardial infarction risk reduction in overweight and obese adults.
Non-Home Treatment Facility Contact Information
Facility Name	Text	Enter the 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 telephone number for the private clinic or hospital where the treatment will be administered. Fill only if 'Home' is 'No'. Depends on: Home
Street Address	Text	Enter the facility’s street address including street number and street name. Fill only if 'Home' is 'No'. Depends on: Home
Suite/Unit	Text	Enter the suite, unit, or room number for the facility address, if applicable. Fill only if 'Home' is 'No'. Depends on: Home
City or Town	Text	Enter the city or town where the facility is located. Fill only if 'Home' is 'No'. Depends on: Home
Province	Text	Enter the province where the facility is located. Fill only if 'Home' is 'No'. Depends on: Home
Postal Code	Text	Enter the facility’s postal code. Fill only if 'Home' is 'No'. Depends on: Home
Other Group Plan Coverage (Has Other Group Plan Yes/No)
Yes	Radiobutton	Check this box if the patient has drug coverage under another group plan.
No	Radiobutton	Check this box if the patient does not have drug coverage under any other group plan.
Other Group Plan Insurance Details
Other Insurance Company Name	Text	Enter the name of the insurance company providing the patient’s other group drug coverage. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Plan Contract Number	Text	Enter the contract number for the patient’s other group insurance plan. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Plan Member Certificate Number	Text	Enter the plan member certificate number for the patient’s other group insurance plan. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Patient Assistance Program Details
Patient Assistance Program Name	Text	Enter the name of the patient assistance program you are enrolled in for the requested drug. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Patient Assistance Program ID Number	Text	Enter the identification number assigned to you by the patient assistance program. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Patient Assistance Program Enrollment (Yes/No)
Yes	Radiobutton	Check this box if the patient has enrolled in the Patient Assistance Program for the requested drug.
No	Radiobutton	Check this box if the patient has not enrolled in the Patient Assistance Program for the requested drug.
Patient Information and Contact
Patient First Name	Text	Enter the patient's first (given) name.
Patient Middle Initial	Text	Enter the patient's middle initial, if applicable.
Patient Last Name	Text	Enter the patient's last (family) name.
Patient Date of Birth	Date	Enter the patient's date of birth.
Relationship to Plan Member	Text	Describe the patient's relationship to the plan member (e.g., self, spouse, child).
Preferred Daytime Phone Number	Text	Enter the patient's preferred daytime phone number.
Patient Email Address (Optional)	Text	Enter the patient's email address if they would like to be contacted by email.
Pediatric Renewal Criteria - Adjunct to Reduced Calorie Diet and Increased Physical Activity
Yes	Radiobutton	Check this box if, for pediatric renewal, the drug will be used as an adjunct to a reduced-calorie diet and increased physical activity. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
No	Radiobutton	Check this box if, for pediatric renewal, the drug will not be used as an adjunct to a reduced-calorie diet and increased physical activity. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
Pediatric Renewal Criteria - BMI Improvement From Baseline
BMI improvement from baseline - Yes	Radiobutton	Check this box if the patient’s BMI has improved from baseline (i.e., decreased with treatment). Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
BMI improvement from baseline - No	Radiobutton	Check this box if the patient’s BMI has not improved from baseline (i.e., has not decreased with treatment). Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
Pediatric Renewal Criteria - Combination With Other GLP-1 Analogs
Used in combination with other GLP-1 analogs (Renewal) - Yes	Radiobutton	Check this box if, for renewal, the drug will be used in combination with another GLP-1 analog. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
Used in combination with other GLP-1 analogs (Renewal) - No	Radiobutton	Check this box if, for renewal, the drug will not be used in combination with another GLP-1 analog. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
Pediatric Renewal Criteria - Continued Benefit
Continued benefit: Yes	Radiobutton	Check this box if the drug continues to provide benefit to the pediatric patient. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
Continued benefit: No	Radiobutton	Check this box if the drug does not continue to provide benefit to the pediatric patient. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
Pediatric Renewal Criteria - Wegovy Dose Exceeds 2.4mg Once Weekly
Yes	Radiobutton	Check this box if the prescribed Wegovy dose will exceed 2.4 mg once weekly for pediatric renewal. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
No	Radiobutton	Check this box if the prescribed Wegovy dose will not exceed 2.4 mg once weekly for pediatric renewal. Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
Pediatric Renewal Criteria Section Identifier
Chronic Weight Management (pediatric) - Renewal Criteria	Radiobutton	Check this box to indicate the request is for renewal criteria under Chronic Weight Management (pediatric). Fill only if 'Before joining Manulife, were you receiving coverage for this drug through your previous insurance company' is 'Yes'. Depends on: Previously covered for this drug (before joining Manulife) – Yes
Physician authorization
Physician authorization date	Date	Enter the date the prescribing physician signed and authorized this form.
Plan Member Address
Street Address	Text	Enter the plan member’s street address including the street number and street name.
Apartment/Suite	Text	Enter the plan member’s apartment, unit, or suite number (if applicable).
City or Town	Text	Enter the city or town for the plan member’s address.
Province	Text	Enter the province for the plan member’s address.
Postal Code	Text	Enter the postal code for the plan member’s address.
Plan Member Identification
Plan Contract Number	Text	Enter the plan contract number for the group benefits plan.
Plan Member Certificate Number	Text	Enter the plan member’s certificate number as shown on the benefits card or plan documents.
Plan Sponsor	Text	Enter the name of the plan sponsor (e.g., employer or organization providing the plan).
Plan Member First Name	Text	Enter the plan member’s first name.
Plan Member Middle Initial	Text	Enter the plan member’s middle initial.
Plan Member Last Name	Text	Enter the plan member’s last name.
Plan Member Date of Birth	Date	Enter the plan member’s date of birth.
Prescribing Physician Address
Street Address	Text	Enter the prescribing physician’s street address including the street number and street name.
Suite/Unit	Text	Enter the prescribing physician’s suite, unit, or apartment number (if applicable).
City or Town	Text	Enter the city or town for the prescribing physician’s address.
Province	Text	Enter the province for the prescribing physician’s address.
Postal Code	Text	Enter the postal code for the prescribing physician’s address.
Prescribing Physician Contact Information
Telephone Number	Text	Enter the prescribing physician’s primary telephone number.
Telephone Extension	Text	Enter the extension for the prescribing physician’s telephone number, if applicable.
Fax Number	Text	Enter the prescribing physician’s fax number.
Prescribing Physician Identification
Prescribing physician first name	Text	Enter the prescribing physician’s first (given) name.
Prescribing physician last name	Text	Enter the prescribing physician’s last (family) name.
College/License number	Text	Enter the prescribing physician’s professional college or medical license number.
Physician specialty	Text	Enter the prescribing physician’s medical specialty.
Provincial Program Application Status
Yes	Radiobutton	Check this box if an application has been made to the provincial program for coverage.
No	Radiobutton	Check this box if an application has not been made to the provincial program for coverage.
Reason Provincial Application Not Submitted	Text	Provide the reason the patient has not applied to the provincial program for coverage. Fill only if 'No' is 'Yes'. Depends on: No
Provincial Program Coverage Approval Status
Yes	Radiobutton	Check this box if the patient has been approved for coverage by the provincial program for this drug.
No	Radiobutton	Check this box if the patient has not been approved for coverage by the provincial program for this drug.
Reason Coverage Was Declined	Text	Provide the reason the provincial program did not approve coverage for this drug, if the patient was not approved. Fill only if 'No' is 'Yes'. Depends on: No
Recent Coverage Change Questions
Drug benefits recently transferred to Manulife – Yes	Radiobutton	Check this box if your plan sponsor recently transferred your drug benefits to Manulife.
Drug benefits recently transferred to Manulife – No	Radiobutton	Check this box if your plan sponsor did not recently transfer your drug benefits to Manulife.
Previously covered for this drug (before joining Manulife) – Yes	Radiobutton	Check this box if, before joining Manulife, you were receiving coverage for this drug through your previous insurance company.
Previously covered for this drug (before joining Manulife) – No	Radiobutton	Check this box if, before joining Manulife, you were not receiving coverage for this drug through your previous insurance company.
Renewal Criteria Questions (Yes/No Responses)
Continued benefit documented – Yes	Radiobutton	Check this box if there is documented objective evidence of continued benefit for this patient.
Continued benefit documented – No	Radiobutton	Check this box if there is not documented objective evidence of continued benefit for this patient.
Used with other GLP-1 analogs – Yes	Radiobutton	Check this box if the drug will be used in combination with other GLP-1 analogs.
Used with other GLP-1 analogs – No	Radiobutton	Check this box if the drug will not be used in combination with other GLP-1 analogs.
Wegovy dose exceeds 2.4 mg weekly – Yes	Radiobutton	Check this box if the Wegovy dose will exceed 2.4 mg once weekly.
Wegovy dose exceeds 2.4 mg weekly – No	Radiobutton	Check this box if the Wegovy dose will not exceed 2.4 mg once weekly.
Second Drug Therapy Row
Drug name (second therapy)	Text	Enter the name of the drug used for the second previous or current therapy.
Start date (second therapy)	Date	Enter the date when the patient started taking this drug for the second therapy.
End date (second therapy)	Date	Enter the date when the patient stopped taking this drug for the second therapy.
Intolerance (Allergy/Adverse Event)	Radiobutton	Check this box if the outcome of this (second-row) drug therapy was intolerance such as an allergy or other adverse event.
Inadequate/Suboptimal Response	Radiobutton	Check this box if the outcome of this (second-row) drug therapy was an inadequate or suboptimal clinical response.
Yes (continuing medication with new therapy)	Radiobutton	Check this box if the patient will continue this (second-row) medication in addition to the new therapy.
No (not continuing medication with new therapy)	Radiobutton	Check this box if the patient will not continue this (second-row) medication when starting the new therapy.
Third Drug Therapy Row
Drug name (Third therapy)	Text	Enter the name of the third previous or current drug therapy used for the selected diagnosis.
Start date (Third therapy)	Date	Enter the date when the patient started the third drug therapy.
End date (Third therapy)	Date	Enter the date when the patient ended the third drug therapy.
Intolerance (Allergy/Adverse Event)	Radiobutton	Check this box if the outcome of this (third) drug therapy was intolerance, such as an allergy or other adverse event.
Inadequate/Suboptimal Response	Radiobutton	Check this box if the outcome of this (third) drug therapy was an inadequate or suboptimal clinical response.
Yes (continuing medication with new therapy)	Radiobutton	Check this box if the patient will continue this (third) medication in addition to the new therapy.
No (not continuing medication with new therapy)	Radiobutton	Check this box if the patient will not continue this (third) medication in addition to the new therapy.
Treatment Administration Location (Select One)
Home	Radiobutton	Check this box if the treatment will be administered at the patient’s home.
MD office	Radiobutton	Check this box if the treatment will be administered in the prescribing physician’s (MD) office.
Private Clinic	Radiobutton	Check this box if the treatment will be administered at a private clinic.
Hospital/In-Patient	Radiobutton	Check this box if the treatment will be administered during an inpatient hospital stay.
Hospital/Out-patient	Radiobutton	Check this box if the treatment will be administered at a hospital on an outpatient basis.
Use in Combination With Other GLP-1 Analogs (Yes/No)
Yes	Radiobutton	Check this box if the drug will be used in combination with other GLP-1 analogs.
No	Radiobutton	Check this box if the drug will not be used in combination with other GLP-1 analogs.
Used in Combination With Other GLP-1 Analogs (Yes/No)
Yes	Radiobutton	Check this box if the drug will be used in combination with other GLP-1 analogs.
No	Radiobutton	Check this box if the drug will not be used in combination with other GLP-1 analogs.
Wegovy Dose Exceeds 2.4 mg Once Weekly (Yes/No)
Yes	Radiobutton	Check this box if the prescribed Wegovy dose will exceed 2.4 mg once weekly.
No	Radiobutton	Check this box if the prescribed Wegovy dose will not exceed 2.4 mg once weekly.
Yes	Radiobutton	Check this box if the prescribed Wegovy dose will exceed 2.4 mg once weekly.
No	Radiobutton	Check this box if the prescribed Wegovy dose will not exceed 2.4 mg once weekly.
Will dose of Wegovy exceed 2.4mg once weekly?
Yes	Radiobutton	Check this box if the prescribed Wegovy dose will exceed 2.4 mg once weekly. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
No	Radiobutton	Check this box if the prescribed Wegovy dose will not exceed 2.4 mg once weekly. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
Will drug be used adjunctive to a reduced calorie diet and increased physical activity?
Yes	Radiobutton	Check this box if the drug will be used as an adjunct to a reduced-calorie diet and increased physical activity. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
No	Radiobutton	Check this box if the drug will not be used as an adjunct to a reduced-calorie diet and increased physical activity. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
Will drug be used in combination with other GLP-1 analogs?
Yes	Radiobutton	Check this box if the drug will be used in combination with other GLP-1 analogs. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.
No	Radiobutton	Check this box if the drug will not be used in combination with other GLP-1 analogs. Fill only if 'Diagnosis for which the drug has been prescribed' is 'Chronic Weight Management (adult) - Renewal Criteria'.

Manulife Group Benefits Drug Prior Authorization Form (Wegovy/Semaglutide) – GL5197E - MLI (08/2025-WEGOV) Instructions