Desjardins Insurance group plans use this two-page request when a patient on a reference (originator) biologic seeks an exemption from the transition to a biosimilar. It is considered only if the patient is currently treated with the drug and it is covered by a public or private plan, and approval needs an acceptable medical reason, such as pregnancy, a pediatric patient or failure of two other biologics.
The plan member completes sections A and C, including the drug's DIN and signatures, with any insured dependent aged 16 or over also signing; the attending physician completes section D, the physician's statement, and section E, identification.
Download the current version from the source each time; forms change without notice.
Request for reimbursement of reference biologic drugs
Demande de remboursement pour un médicament biologique de référence
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Desjardins links this reference biologic form as the brand option for Humira. An exemption is considered only if the patient is currently treated with the drug and it is covered by a public or private plan, and the physician must give an acceptable reason such as pregnancy, a pediatric patient or failure of two other biologics.
The physician can check a pregnant patient (with due date), a pediatric patient, or a patient for whom at least two other biologic drugs have failed, listing them. Any other reason must come with sufficiently documented medical justification, and Desjardins' physician or pharmacist may review the file.
Yes. The French version, Demande de remboursement pour un médicament biologique de référence, is numbered 21084F, and the English form is 21084E, revised 2026-07. Desjardins posts both with its group insurance claim forms.