Pharmacy Barriers to Naloxone Access Form
Please fill out this form if you or someone you know was unable to obtain naloxone at a pharmacy in Philadelphia, PA through the standing order.
Name of pharmacy: *
Address of pharmacy: *
Staff you spoke with: *
Was staff familiar with PA Standing Order? *
Was the pharmacist willing to fill the order? *
If not, what was the reason given?
Did the pharmacy have any form of naloxone in stock?
Clear selection
If known, which versions of naloxone were in stock?
If the pharmacy was out of stock, what did staff recommend?
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Was high cost a barrier to obtaining naloxone?
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Do you have insurance?
Clear selection
If yes, was the pharmacist willing to bill your insurance?
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How much was your reported cost?
If you experienced any other barriers to obtaining naloxone, please explain the circumstances below:
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