Forms & Resources

Enrollment unlocks 1⁠-⁠on⁠-⁠1 support and resources

Enrollment Form
Enrollment Form Icon

Enrolling in YourBlueprint® is simple: complete the enrollment form and make sure your patient provides their consent and authorization

Enrollment form

To initiate enrollment, print and complete the enrollment form with your patient and fax it to 1-866-370-3082.

Additional ways to obtain patient consent and authorization

Regardless of which product is being prescribed, if your patient did not provide consent in person, they can provide it either:

Dose exchange program

Complete the AYVAKIT dose exchange form to allow patients for whom

you prescribe a change in their dose of AYVAKIT to exchange remaining

medication for the new dose.

Other Forms and Resources

Additional tools to help start your patients on a Blueprint Medicines therapy

Program overview for patients

Download a patient program overview to inform your patients about the support YourBlueprint provides.

Program overview for providers

Inform your office and others about YourBlueprint with the program overview for providers.

 
AYVAKIT access and reimbursement guide
This comprehensive guide provides detailed information about product ordering, distribution, YourBlueprint patient support, coverage, and access for AYVAKIT. It includes helpful resources such as documentation checklists for prior authorizations and appeals, sample letters for appeals, medical necessity and formulary exceptions, and a diagnostic testing, billing, and coding guide.
Sample letter of medical necessity

Download a sample letter to provide in case you need to confirm the medical necessity and appropriateness of a Blueprint Medicines therapy for your patient. Once appropriately modified and completed, submit it to your patient’s insurer.

 
 
Sample letter of appeal

Download a sample letter of appeal to use in the event your patient is denied coverage for a Blueprint Medicines therapy. Once appropriately modified and completed, submit it to your patient’s insurer.

 
 
 
Sample formulary exception letter

Download this sample letter to use as a guide to request a formulary exemption for a Blueprint Medicines therapy for your patient. Once appropriately modified and completed, submit it to your patient’s insurer.

 
 
 
 
Prior authorization checklist

This comprehensive checklist provides guidance on submitting a prior authorization to an insurer and suggested documents to include.

 
 
 
 
 
Appeal checklist
This comprehensive checklist provides guidance on submitting an appeal to an insurer and suggested documents to include.
Formulary exceptions checklist

This comprehensive checklist provides guidance on submitting a formulary exception request to an insurer and suggested documents to include.

 
 
 
 
 
 
 
Medically Integrated Dispenser (MID) Co-Pay Instructions
Follow these simple instructions to ensure your practice pharmacy is contracted with our claims processor and can receive reimbursement for the Co⁠-⁠Pay Assistance Program.
Patient Priority Icon

YourBlueprint: Our priority is your patient