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: *
Your answer
Address of pharmacy: *
Your answer
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?
Your answer
Did the pharmacy have any form of naloxone in stock?
If known, which versions of naloxone were in stock?
If the pharmacy was out of stock, what did staff recommend?
Was high cost a barrier to obtaining naloxone?
Do you have insurance?
If yes, was the pharmacist willing to bill your insurance?
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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