Sample Letter for Formulary Exceptions

The value of this program is exclusively for the benefit of enrolled patients and is intended to be credited toward patient out-of-pocket obligations, including applicable co-payments, co-insurance, and deductibles. Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account. Patient is responsible for complying with any applicable limitations and requirements of his/her health plan related to the use of the program. Program is not valid where prohibited by law. Valid only in the United States and U.S. Territories. This program is not health insurance. This program may not be combined with any third-party rebate, coupon, or offer. Offer is not available to patients whose prescription claims are eligible to be reimbursed, in whole or in part, by any governmental program, such as patients enrolled in Medicare Part D and patients whose prescription is paid for by Medicare, Medicaid, Medigap, CHAMPUS, Department of Defense (DoD), TRICARE, Veterans Affairs (VA), Children’s Heath Insurance Program (CHIP), the Indian Health Service, or a state pharmaceutical assistance program. Blueprint Medicines reserves the right to rescind, revoke, or amend the program and discontinue support at any time without notice. Offer is not valid if the patient is uninsured or paying cash for the prescription. If you have any questions, please contact customer support at 1-888-BLUPRNT (1-888-258-7768).