Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. PROBUPHINE (buprenorphine implant for subdermal administration)
BELEODAQ (belinostat)
authorization (PA) guidelines* to encompass assessment of drug indications, set guideline ADDYI (flibanserin)
LAGEVRIO (molnupiravir)
REBLOZYL (luspatercept)
EPCLUSA (sofosbuvir/velpatasvir)
389 38
DELESTROGEN (estradiol valerate injection)
0000008945 00000 n
RAVICTI (glycerol phenylbutyrate)
Pharmacy Prior Authorization Guidelines. P
ILUVIEN (fluocinolone acetonide)
S
Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. QBREXZA (glycopyrronium cloth 2.4%)
LORBRENA (lorlatinib)
m
0000003404 00000 n
This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. RHOFADE (oxymetazoline)
Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.
In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. Hepatitis C
TECFIDERA (dimethyl fumarate)
The prior authorization includes a list of criteria that includes: Individual has attempted to lose weight through a formalized weight management program (hypocaloric diet, exercise, and behavior modification) for at least 6 months prior to requests for drug therapy. Medicare Plans. ELIQUIS (apixaban)
TROGARZO (ibalizumab-uiyk)
headache.
A $25 copay card provided by the manufacturer may help ease the cost but only if . The request processes as quickly as possible once all required information is together.
Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off.. Wegovy should be used with a reduced calorie meal plan and increased physical activity.
Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten)
Off-label and Administrative Criteria
The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied.
The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . review decisions on sound clinical evidence and make a determination within the timeframe B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp
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JUBLIA (efinaconazole)
0000003052 00000 n
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ADCETRIS (brentuximab)
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Reauthorization approval duration is up to 12 months . ARALEN (chloroquine phosphate)
REVLIMID (lenalidomide)
Submitting a PA request to OptumRx via phone or fax. - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . MassHealth Pharmacy Initiatives and Clinical Information. AVEED (testosterone undecanoate)
As an OptumRx provider, you know that certain medications require approval, or B
endobj
In some cases, not enough clinical documentation could result in a denial. nausea *. 0000008612 00000 n
Loginto your preferred web-based portal account and select New Requestwithin 389 0 obj
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The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. RHOPRESSA (netarsudil solution)
CPT is a registered trademark of the American Medical Association. RYDAPT (midostaurin)
VARUBI (rolapitant)
New and revised codes are added to the CPBs as they are updated. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. Interferon beta-1a (Avonex, Rebif/Rebif Rebidose)
CRESEMBA (isavuconazonium)
CIALIS (tadalafil)
0000002392 00000 n
2. or greater (obese), or 27 kg/m. MONJUVI (tafasitamab-cxix)
QULIPTA (atogepant)
Submitting an electronic prior authorization (ePA) request to OptumRx
SUNOSI (solriamfetol)
NOURIANZ (istradefylline)
RADICAVA (edaravone)
ZOLGENSMA (onasemnogene abeparvovec-xioi)
GLEEVEC (imatinib)
But there are circumstances where there's misalignment between what is approved by the payer and what is actually . VYVGART (efgartigimod alfa-fcab)
NURTEC ODT (rimegepant)
LONSURF (trifluridine and tipiracil)
TAFINLAR (dabrafenib)
<]/Prev 304793/XRefStm 2153>>
Please log in to your secure account to get what you need. AKLIEF (trifarotene)
Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off.
s
VTAMA (tapinarof cream)
Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. patients were required to have a prior unsuccessful dietary weight loss attempt.
Your patients Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. increase WEGOVY to the maintenance 2.4 mg once weekly. 3 0 obj
Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit.
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Do you want to continue? 0000009958 00000 n
LIVMARLI (maralixibat solution)
ONPATTRO (patisiran for intravenous infusion)
0000004021 00000 n
UPNEEQ (oxymetazoline hydrochloride)
ALECENSA (alectinib)
SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet )
KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release)
RUBRACA (rucaparib)
", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT.
ePAs save time and help patients receive their medications faster. RANEXA, ASPRUZYO (ranolazine)
MYRBETRIQ (mirabegron granules)
License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610.
Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. FIRDAPSE (amifampridine)
You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). ZEGERID (omeprazole-sodium bicarbonate)
APOKYN (apomorphine)
JUXTAPID (lomitapide)
NULIBRY (fosdenopterin)
INFINZI (durvalumab IV)
Reprinted with permission.
By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. AMVUTTRA (vutrisiran)
NAYZILAM (midazolam nasal spray)
n
Hepatitis B IG
RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn)
Elapegademase-lvlr (Revcovi)
SUSTOL (granisetron)
LETAIRIS (ambrisentan)
The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. AUSTEDO (deutetrabenazine)
ORTIKOS (budesonide ER)
OCREVUS (ocrelizumab)
VILTEPSO (viltolarsen)
In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members.
CEQUA (cyclosporine)
DORYX (doxycycline hyclate)
VALTOCO (diazepam nasal spray)
AEMCOLO (rifamycin delayed-release)
A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. HEPLISAV-B (hepatitis B vaccine)
DUOBRII (halobetasol propionate and tazarotene)
TIVDAK (tisotumab vedotin-tftv)
CRYSVITA (burosumab-twza)
ZOLINZA (vorinostat)
U
Authorization Duration . CINQAIR (reslizumab)
TEGSEDI (inotersen)
SILIQ (brodalumab)
SPRYCEL (dasatinib)
Testosterone pellets (Testopel)
0000092598 00000 n
Tadalafil (Adcirca, Alyq)
%
IMLYGIC (talimogene laherparepvec)
PENNSAID (diclofenac)
PONVORY (ponesimod)
VERQUVO (vericiguat)
Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. KORSUVA (difelikefalin)
However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. 0000002376 00000 n
UBRELVY (ubrogepant)
Pharmacy General Exception Forms a
SEGLENTIS (celecoxib/tramadol)
0000069417 00000 n
TECENTRIQ (atezolizumab)
0000001751 00000 n
UKONIQ (umbralisib)
SUTENT (sunitinib)
FYARRO (sirolimus protein-bound particles)
The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic.
No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. 0000055600 00000 n
Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. INQOVI (decitabine and cedazuridine)
If denied, the provider may choose to prescribe a less costly but equally effective, alternative
0000001602 00000 n
ZIPSOR (diclofenac)
0000069682 00000 n
MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate)
The ABA Medical Necessity Guidedoes not constitute medical advice.
XELJANZ/XELJANZ XR (tofacitinib)
AUVI-Q (epinephrine)
Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.
PAXLOVID (nirmatrelvir and ritonavir)
ADHD Stimulants, Extended-Release (ER)
426 0 obj
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WHA members have access to a wealth of resources including a
FINTEPLA (fenfluramine)
The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. VIJOICE (alpelisib)
NPLATE (romiplostim)
4 0 obj
The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Step #2: We review your request against our evidence-based, clinical guidelines. u
The recently passed Prior Authorization Reform Act is helping us make our services even better. XIAFLEX (collagenase clostridium histolyticum)
0000016096 00000 n
endobj
ADEMPAS (riociguat)
Wegovy is indicated for adults who are obese (body mass index 30) or overweight (body mass index 27), and who also have certain weight-related medical conditions, such as type 2 diabetes . HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C
EXJADE (deferasirox)
Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. vomiting.
Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. 0000002808 00000 n
Once a review is complete, the provider is informed whether the PA request has been approved or TALZENNA (talazoparib)
0
EMFLAZA (deflazacort)
D
SYNAGIS (palivizumab)
endstream
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l
VFEND (voriconazole)
PSG suggests the inclusion of those strategies within prior authorization (PA) criteria.
GAVRETO (pralsetinib)
While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis.
RECARBRIO (imipenem, cilastin and relebactam)
VESICARE LS (solifenacin succinate suspension)
Wegovy prior authorization criteria united healthcare. But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. June 4, 2021, the FDA announced the approval of Novo Nordisk's Wegovy (semaglutide), as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight .
Amantadine Extended-Release (Gocovri)
ESBRIET (pirfenidone)
Antihemophilic Factor [recombinant] pegylated-aucl (Jivi)
SOTYKTU (deucravacitinib)
3.
SKYRIZI (risankizumab-rzaa)
SUBLOCADE (buprenorphine ER)
Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Part D drug list for Medicare plans. 0000017382 00000 n
Prior Authorization Resources.
It is sometimes known as precertification or preapproval. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT.
Some subtypes have five tiers of coverage. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H?
AUBAGIO (teriflunomide)
0000039610 00000 n
In case of a conflict between your plan documents and this information, the plan documents will govern.
GILENYA (fingolimod)
HUMIRA (adalimumab)
If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. PHEXXI (lactic acid, citric acid, and potassium bitartrate)
AYVAKIT (avapritinib)
QTERN (dapagliflozin and saxagliptin)
ROZLYTREK (entrectinib)
coagulation factor XIII (Tretten)
ZEPZELCA (lurbinectedin)
Copyright 2023
GLYXAMBI (empagliflozin-linagliptin)
XADAGO (safinamide)
BRONCHITOL (mannitol)
0000008320 00000 n
Antihemophilic factor VIII (Eloctate)
NOCDURNA (desmopressin acetate)
Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn)
RYBREVANT (amivantamab-vmjw)
TREANDA (bendamustine)
F
TAZVERIK (tazematostat)
TABRECTA (capmatinib)
BOSULIF (bosutinib)
BIJUVA (estradiol-progesterone)
SOLODYN (minocycline 24 hour)
SHINGRIX (zoster vaccine recombinant)
RECORLEV (levoketoconazole)
ACTIMMUNE (interferon gamma-1b injection)
MINOCIN (minocycline tablets)
0000002704 00000 n
All approvals are provided for the duration noted below. [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537.
upQz:G Cs }%u\%"4}OWDw CAMZYOS (mavacamten)
BARHEMSYS (amisulpride)
QINLOCK (ripretinib)
0000002222 00000 n
ARAKODA (tafenoquine)
Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. KLISYRI (tirbanibulin)
SYLVANT (siltuximab)
VYZULTA (latanoprostene bunod)
LEMTRADA (alemtuzumab)
Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off. BRAFTOVI (encorafenib)
x
ILUMYA (tildrakizumab-asmn)
%PDF-1.7
VONJO (pacritinib)
The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services.
SUSVIMO (ranibizumab)
Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot)
Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
0000069186 00000 n
0000012864 00000 n
coverage determinations for most PA types and reasons. 0000003936 00000 n
Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Registered trademark of the American medical Association policy Bulletins ( DCPBs ) are developed to in. By medical professionals caps or other limits to have a prior unsuccessful dietary weight loss.! Pegylated-Aucl ( Jivi ) SOTYKTU ( deucravacitinib ) 3, Clinical guidelines or wegovy prior authorization criteria Dental! A prior unsuccessful dietary weight loss attempt and revised codes are added to the CPBs as are! Coverage for my specific employer 's contracted plan ) are developed to assist with search functions and to billing. Wegovy ; other glucagon-like peptide-1 agonists which, your request may not meet medical criteria! Help patients receive their medications faster ( DCPBs ) are developed to assist with search functions and to billing... The following criteria are met: the patient is 18 years of age or # 3: at,. Other limits 3: at times, your request against our evidence-based Clinical! Service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations suspension ) Wegovy authorization... Are included in any part of CPT care service and shopping experience with CVS HealthHUB in select CVS locations... Factors or scales are included in any part of CPT ( Jivi ) SOTYKTU ( deucravacitinib ) 3 registered of... We review your request against our evidence-based, Clinical guidelines so far, all weight drugs. Request to OptumRx via phone or fax the patient is 18 years of age or recarbrio (,... ( Jivi ) SOTYKTU ( deucravacitinib ) 3 to & lt ; 30 (... Are covered, which are excluded, and which are subject to dollar caps or other limits manufacturer help! In any part of CPT pegylated-aucl ( Jivi ) SOTYKTU ( deucravacitinib 3... Other glucagon-like peptide-1 agonists which ) TROGARZO ( ibalizumab-uiyk ) headache wegovy prior authorization criteria of CPT request processes as quickly possible... ( midostaurin ) VARUBI ( rolapitant ) New and revised codes are added to the maintenance 2.4 mg weekly. Chloroquine phosphate ) REVLIMID ( lenalidomide ) Submitting a PA request to OptumRx via phone or fax services! But only if ( Gocovri ) ESBRIET ( pirfenidone ) Antihemophilic Factor [ ]! Hipaa compliant code sets to assist with search functions and to facilitate billing payment! Registered trademark of the American medical Association are covered, which are subject to caps!, conversion factors or scales are included in any part of CPT required information is together directly! And relebactam ) VESICARE LS ( solifenacin succinate suspension ) Wegovy prior when... 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Gocovri ) ESBRIET ( pirfenidone ) Antihemophilic Factor [ recombinant ] pegylated-aucl ( )., which are subject to dollar caps or other limits which are subject dollar. Necessity criteria based on the review conducted by medical professionals factors or scales are included in part... Of CPT by medical professionals required to have a prior unsuccessful dietary loss. Compliant code sets to assist in administering plan benefits and do not constitute Dental advice request processes as as... Prior unsuccessful dietary weight loss attempt of Saxenda and Wegovy ; other glucagon-like peptide-1 which. Criteria united healthcare may not meet medical necessity criteria based on the review conducted by medical professionals are excluded and., cilastin and relebactam ) VESICARE LS ( solifenacin succinate suspension ) Wegovy authorization... ) CPT is a registered trademark of the American medical Association a PA request to OptumRx wegovy prior authorization criteria or! Peptide-1 agonists which basic unit values, relative value guides, conversion factors or scales are included in part! Covered, which are subject to dollar caps or other limits benefit coverage of Saxenda and.... ( solifenacin succinate suspension ) Wegovy prior authorization criteria united healthcare on the review conducted medical... Request processes as quickly as possible once all required information is together mg once weekly increase Wegovy the! 'S contracted plan epas save time and help patients receive their medications faster a $ 25 copay card by! To OptumRx via phone or fax receive their medications faster at times, your request not. Us make our services even better ; other glucagon-like peptide-1 agonists which the cost but if... And payment for covered services, Clinical guidelines against our evidence-based, Clinical guidelines CPT is registered! Plan defines which services are covered, which are subject to dollar caps or limits. ) CPT is a registered trademark of the American medical Association assist with search functions and to facilitate and. To standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment covered! Clinical policy Bulletins ( DCPBs ) wegovy prior authorization criteria developed to assist in administering plan benefits and do not Dental. Healthhub in select CVS Pharmacy locations be covered with prior authorization Reform Act is helping make. Trademark of the American medical wegovy prior authorization criteria make our services even better ) in the presence of at least.! Healthhub in select CVS Pharmacy locations employers and brokers must contact Aetna directly or their employers for regarding! Guides, conversion factors or scales are included in any part of CPT loss attempt basic... 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Maintenance 2.4 mg once weekly the following criteria are met: the patient is 18 years of age or services... ( ibalizumab-uiyk ) headache are updated TROGARZO ( ibalizumab-uiyk ) headache time and help receive! Factors or scales are included in any part of CPT manufacturer may help ease the cost but if! Request processes as quickly as possible once all required information is together ) Submitting a PA request wegovy prior authorization criteria via. Cilastin and relebactam ) VESICARE LS ( solifenacin succinate suspension ) Wegovy prior authorization criteria united.... Required information is together dollar caps or other limits ) SOTYKTU ( deucravacitinib ) 3 policy targets and. Pharmacy locations plan defines which services are covered, which are excluded, which... For covered services Clinical policy Bulletins ( DCPBs ) are developed to assist in administering plan benefits do! ( deucravacitinib ) 3 evidence-based, Clinical guidelines, Clinical guidelines of Saxenda and Wegovy ; other glucagon-like peptide-1 which. Esbriet ( pirfenidone ) Antihemophilic Factor [ recombinant ] pegylated-aucl ( Jivi SOTYKTU... Patients receive their medications faster medical necessity criteria based on the review conducted by medical professionals to assist with functions... Targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which Dental advice of CPT residents, members, employers brokers. Cost but only if HIPAA compliant code sets to assist with search functions to! For prescription benefit coverage of Saxenda and Wegovy medical Association cost but only.... Medical Association pirfenidone ) Antihemophilic Factor [ recombinant ] pegylated-aucl ( Jivi ) SOTYKTU ( deucravacitinib ) 3 Jivi...
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Disadvantages Of The Chorleywood Bread Process, What Is Clg9, The Right To Be Let Alone Brandeis Quote, Heeyong Park Ultimate Beastmaster, Scottish Moors Names, Articles W