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.
* Required
Name of pharmacy:
*
Your answer
Address of pharmacy:
*
Your answer
Staff you spoke with:
*
Pharmacist
Pharmacy Technician
Both
Was staff familiar with PA Standing Order?
*
Yes
No
Was the pharmacist willing to fill the order?
*
Yes
No
If not, what was the reason given?
Your answer
Did the pharmacy have any form of naloxone in stock?
Yes
No
Not Sure
Clear selection
If known, which versions of naloxone were in stock?
Generic IMS Naloxone
Narcan
Evzio
Don't Know
If the pharmacy was out of stock, what did staff recommend?
Offered to order it
Recommended another pharmacy
No recommendation was given
N/A
Other:
Clear selection
Was high cost a barrier to obtaining naloxone?
Yes
No
N/A
Clear selection
Do you have insurance?
Yes
No
Clear selection
If yes, was the pharmacist willing to bill your insurance?
Yes
No
N/A
Clear selection
How much was your reported cost?
Your answer
If you experienced any other barriers to obtaining naloxone, please explain the circumstances below:
Your answer
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