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145 The West Mall P. O. Box 110 U Toronto ON M8Z 5M4 PRIOR AUTHORIZATION PROGRAM FORM Fampyra Fampridine Instructions 1. If the patient has another drug plan prior authorization may cover some or all of the excess not paid by the primary plan. Please indicate if the patient meets the following qualifying criteria for drug coverage Fampyra sustained release tablets are indicated for the symptomatic improvement of walking in adult patients with multiple sclerosis MS with walking disability...
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