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 F54-1025A: Reference Biologic Drug Exception
iA Financial Group's group plans use this one-page request when a member needs a reference biologic drug rather than a biosimilar version. The attending physician states the reason, such as pregnancy, a pediatric patient, or failure of at least two other biologic drugs for the same condition. iA reviews the request and informs the member whether it is approved.
Who completes it
The member completes Section 2 and signs the Section 4 confirmation and authorization; the attending physician completes Section 3, the Attending Physician's Statement, with 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, based on the member's province of residence.
Good to know
- Reasons on the form are a pregnant patient (with due date), a pediatric patient, failure of at least two other biologic drugs for the same condition, or another documented medical reason.
- When citing failed therapy, the physician lists the biologic drugs tried; the form requires at least two other biologics to have failed for the same medical condition.
- Members should not submit a claim before receiving approval; iA reviews each request and informs the member whether the exception is approved.
- The physician records the reference biologic's DIN, dosage and frequency, and anticipated duration. The current English version is F54-1025A, dated January 2023.
Get the official form
Download the current version from the source each time; forms change without notice.
Request for reference biologic drug exception
Formulaire d’exception pour un médicament biologique
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
When does iA consider covering a reference biologic instead of a biosimilar?
iA's form recognizes a pregnant patient, a pediatric patient, a patient for whom at least two other biologic drugs have failed for the same condition, or another documented medical reason. The attending physician ticks the reason, adds details such as the due date or the biologics tried, and signs.
Is iA's reference biologic exception form available in French?
Yes. iA publishes 'Formulaire d'exception pour un médicament biologique' (F54-1025) in French alongside the English F54-1025A. The English version is a single page dated January 2023 and is sent to Group Health and Dental Claims, with separate offices for Quebec and the other provinces.
What does the physician need to provide on F54-1025A?
In Section 3 the attending physician names the requested reference biologic and its DIN, gives the dosage, frequency and anticipated duration of therapy, selects the reason for the request with supporting details, and adds name, address, phone, fax, licence number, signature and date.