Forms & Resources
Access forms and program resources from YourBlueprint® below.
Program overview for HCPs
Inform your office and other providers about YourBlueprint’s offerings.
Program overview for patients
Inform your patients about YourBlueprint’s support options.
Getting your patient access to YourBlueprint is simple. To initiate enrollment, complete the form and make sure your patient provides their consent and authorization.
Enrollment form instructions
Be sure to completely fill in the enrollment form, including prescription details and HCP signature.
Patient consent required
Your patient can provide consent in person or online through DocuSign.
Prior authorization checklist
Follow this checklist for guidance on submitting a prior authorization to an insurer and suggested documents to include.
Sample letter of medical necessity
Download this sample letter if you need to confirm the medical necessity of a Blueprint Medicines therapy for your patient. Once appropriately modified and completed, submit it to your patient’s insurer.
Appeals request checklist
Get guidance on submitting an appeal to an insurer and suggested documents to include.
Sample letter of appeal
Use in the event your patient is denied coverage. Once appropriately modified and completed, submit it to your patient’s insurer.
Sample formulary exception letter
Use as a guide to request a formulary exemption for your patient and submit it to your patient’s insurer once completed.
Dose exchange form
Complete the form for eligible patients who have had a dosage change so they can exchange remaining medication for the new dose at no cost.
Co-pay enrollment application
Eligible, commercially insured patients can reduce their out-of-pocket costs (co-pay, co-insurance or deductible) to as little as $0 per month.*
*Up to an annual maximum benefit of $25,000. Terms and conditions apply.
Co-pay processing instructions
Follow these instructions to ensure your practice pharmacy is contracted with the claims processor and can receive reimbursement for the Co-Pay Assistance Program.
Product order sheet
Blueprint Medicines are only available through a limited network of specialty pharmacies and distributors.
Access and reimbursement guide
Get information and resources about product ordering, distribution, YourBlueprint patient support, coverage and medication access.