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Please indicate the patient's dose for this medication. The plan allows for coverage of 2 capsules per day of , 35 tablets per year of Xalreto 10 mg, 2 tablets per day of Xalreto 15mg, 1 tablet per day of Xalreto 20mg, 74 tablets per 30 days of , and 1 tablet per day of Savaysa. If the patient's dose is in excess of this amount, please explain. Q7. Has the patient been started on and stabilized on the requested medication? Yes No Q8. Is the patient unable to take for o.

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