Navigating Coverage

We’re Here To Help With Access

At YourBlueprint^®, we work together with your staff and your patient’s pharmacy to help your patient obtain the medication needed.

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Coverage approval process

Your patient's Case Manager can help facilitate access to therapy.

The pharmacy will verify your patient’s insurance coverage and work directly with your office to obtain prior authorization.

Once approved, the pharmacy will contact the patient about any out-of-pocket costs and schedule medication delivery.

The Case Manager will coordinate with the pharmacy and your staff to assess if your patient is eligible for financial assistance or temporary medication, as needed, along the way.

Prior authorization support

YourBlueprint can help you navigate the prior authorization process for your patient.

Whether your office prefers to initiate the prior authorization before you enroll your patient in YourBlueprint or after, completing the prior authorization correctly the first time will help minimize unnecessary treatment delays. To expedite the process, be sure to submit the required documentation along with the enrollment form.

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Prior authorization resources

Approval process requirements vary by payer. These resources are provided to help you navigate the process.

Prior authorization checklist

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Sample letter of medical necessity

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Denials & appeals

In the event of a prior authorization denial, you can request reconsideration by providing additional guidance, a documentation checklist or a sample letter of medical necessity or appeal.

Common reasons for claim denials

Here are a few reasons for denials that may be resolvable through the appeals or formulary exception request process.

Missing information

Check that the coverage request isn’t missing information, like the appropriate diagnosis code, or lab values required by the drug's label.

Prior authorization required

Be sure to submit the prior authorization and all required information at time of prescription request.

Insurance information changes

Ensure you have your patient’s most up-to-date insurance information.

Appeals process

If a request for coverage of your patient’s Blueprint Medicines therapy is denied, it may be resolvable through the standard appeals process, which consists of three levels:

1^st level appeal

Contact payer to request a consideration of the denial. This may include a “peer-to-peer” discussion with the medical reviewer.

2^nd level appeal

At this step, the appeal is typically reviewed by the plan’s medical director to determine if the request should be accepted within the coverage guidelines.

Independent external review

If appeals have not been successful, an external review can be conducted by an independent third party to make a binding decision.

Patients may also assist with the appeals process

If a request for coverage is denied, patients can contact their employer’s benefits administrator or their health plan for additional information on how to appeal the payer’s decision or to request an external review. In some cases, it may be necessary to submit a formulary exception request to the payer. Download the Appeals Request Checklist for more information.

Appeals request checklist

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Sample letter of appeal

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Sample formulary exception request

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