Physician's proof-of-death statement for iA Special Markets (association/affinity group) accidental death claims.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Language
- English
iA F54-835A: Request for Brand Name Drug Exception
iA Financial Group's group plans use this one-page request when a member needs a brand-name drug instead of its generic equivalent for medical reasons. The attending physician documents the reason, such as an allergic reaction or intolerance to a non-medicinal ingredient present in the generic but absent in the brand. iA reviews the request and tells the member whether it is approved.
Who completes it
The member completes Section 2 (member and patient information) and signs the Section 4 authorization; the attending physician completes Section 3, the Attending Physician's Statement, including licence number and signature.
Submitting and payment
- How to submit it
- Mail or fax the form to iA's Group Health and Dental Claims, using the Quebec address and fax line or the ones for all other provinces, according to the member's province of residence.
Good to know
- Members should not submit the drug claim before receiving approval; otherwise iA reimburses it at the cost of the lowest-priced generic equivalent.
- Reasons offered are a documented allergic reaction or documented intolerance to a non-medicinal ingredient present in the generic but absent in the brand, or another documented medical reason.
- If the generic was used, the physician gives the date therapy began, the date of the adverse reaction and its nature, extent and severity; if not, why it was not used.
- The physician also records the requested brand's DIN, dosage and frequency, and anticipated duration of therapy. The current English version is dated August 2021 (21-08).
Get the official form
Download the current version from the source each time; forms change without notice.
Request for brand name drug exception
Formulaire d'exception pour un médicament d'origine
Fill it with Vero
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Frequently asked questions
What reasons does iA accept for a brand name drug exception?
The form lists three: a documented allergic reaction to a non-medicinal ingredient present in the generic but absent in the brand, a documented intolerance to such an ingredient, or another documented medical reason. The attending physician ticks one, describes it and signs the Attending Physician's Statement.
Is iA's brand name drug exception form available in French?
Yes. iA publishes a French version, 'Formulaire d'exception pour un médicament d'origine' (F54-835), alongside the English F54-835A on its forms pages. The English version is a single page, revised in August 2021, with sections for the member, the attending physician and the member's authorization.
Can the member claim the brand-name drug before approval?
The form advises against it. If a claim is submitted before the member receives approval, iA reimburses it at the cost of the lowest-priced generic equivalent. iA reviews each request and informs the member whether or not the exception has been approved.