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 F54-859A: Request for Prior Authorization (Drugs)
iA Financial Group's group plans need approval before reimbursing drugs on iA's prior authorization list, and this general form covers listed drugs that have no specific variant. Clinicians meet it for initial claims and for renewals, since approvals last a set period. iA reviews the request against the plan's coverage criteria and expects to notify the member within 10 days of receipt.
Who completes it
The plan member or patient completes and signs Part 1, including other coverage and financial assistance; the prescribing physician answers the nine questions in Part 2 on the drug, diagnosis, clinical status and treatment history, then signs.
Submitting and payment
- How to submit it
- Fax or mail the form to iA's Health and Dental Claims Department (Quebec or all other provinces, by residence), or send it through Secure Messaging in iA's My Client Space.
- Who pays
- iA's instructions state that any fees for completing the form are the responsibility of the plan member or patient.
Good to know
- Part 2 asks for a copy of the current consultation report, or the most recent report for a renewal, plus any information supporting use of the drug for this patient.
- iA has separate variants for weight management and obesity drugs (54-1076A), semaglutide (54-859A-122), Mounjaro (54-859A-121) and the FreeStyle Libre sensor (F54-1035A).
- In Quebec, drugs on the RAMQ exception drug list must also meet the criteria for coverage under the member's plan.
- Approvals cover a specific period; iA's brochure says a renewal request must then be submitted so iA can confirm the patient is responding to treatment.
Get the official form
Download the current version from the source each time; forms change without notice.
Request for prior authorization – Drugs
Formulaire d’autorisation préalable – Médicaments
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Which iA form should I use for prior authorization?
Check iA's list of drugs requiring prior authorization (F54-1018A). Use the drug-specific variant where one exists, such as for semaglutide, Mounjaro, weight-management drugs or the FreeStyle Libre sensor; otherwise use the general F54-859A request, ticking Initial claim or Renewal at the top.
How long does iA take to decide a prior authorization request?
iA says the member can expect notification within 10 days of when the request is received. Assessment is delayed if the form is incomplete or contains errors, and the member can check the claim's status by logging in to My Client Space.
What does the physician answer on iA form F54-859A?
Part 2 covers the drug and dosage regimen, the diagnosis, expected duration, current clinical status including stage and severity, all previous and current treatments with results, hospital administration, available alternatives and any clinical study participation. The physician indicates general practitioner, specialist or other and gives a licence number.