Consumer Survey - CalRx

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Consumer Survey

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We appreciate your time and feedback—this survey is designed to help us better understand your needs and improve your experience with our products and services.

Consumer Survey

We appreciate your time and feedback—this survey is designed to help us better understand your needs and improve your experience with our products and services.

Please indicate the medication this survey pertains to(Required)

CalRx Insulin

CalRx Naloxone

CalRx Insulin Survey

County of Residence(Required)

Age Group(Required)

0 – 19

20 – 64

65 +

How did you receive CalRx insulin?(Required)

Mail order pharmacy

Retail pharmacy

Type of pharmacy(Required)

Major retail pharmacy chain (e.g., CVS, Walgreens, Costo, Safeway, Wal-Mart, or similar)

Independent retail pharmacy (not affiliated with a major retail pharmacy chain)

Type of Insurance(Required)

Commercial PPO

Commercial HMO

Medi-Cal

Medicare

Medicare Advantage

Not applicable, I did not use insurance

Did you have any issue with your insurance covering the medication?(Required)

Yes

No

Not applicable

If “Yes”, what issues did you have?

How much did you pay for this medication?(Required)

$1 – $5

$5.01 – $35

$35.01 – $55

More than $55

Why did you choose this CalRx insulin vs. other brands? (Select all that apply)(Required)

Recommended by a healthcare provider

Lower cost

Easier to access

Other

If “Other”, please specify(Required)

How did you hear about this medication?(Required)

Friend or family recommended

Online search

Advertising (TV/Radio/Online)

Healthcare provider referral

CalRx website

Other

If “Other”, please specify

Do you plan to, or have you, refilled this medication?(Required)

Yes

No

If “No”, why not?

Is there anything else that you’d like to share with the CalRx team about your experience with obtaining and using our product?

ACKNOWLEDGMENT(Required)

By providing your information on our CalRx Consumer Survey, you acknowledge that you have reviewed the CalRx Data Collection/Condition of Use and Privacy Policy Statement.

Please do not include any protected health information, such as your medical diagnosis.

CalRx Resources: Data Collection/Condition of Use and Privacy Policy Statement

CalRx Naloxone Survey

County of residence(Required)

Age Group(Required)

0 – 19

20 – 64

65 +

How did you obtain CalRx Naloxone?(Required)

Community organization

School or university

County public health, behavioral health agency

Tribal entity

Hospital or emergency department

Community clinic or health center

Fire, police, or emergency medical services

CalRxNaloxone.com

Other

If “Other”, please specify

How much did you pay for this medication per twin-pack box, excluding shipping and handling, if applicable?(Required)

$0

$1 – $23

More than $23

How did you hear about CalRx Naloxone?(Required)

Friend or family recommended

Online search

Advertising (TV/Radio/Online)

Healthcare provider referral

CalRx website

DHCS Naloxone Distribution Project

Other

If “Other”, please specify

ACKNOWLEDMENT(Required)

By providing your information on our CalRx Contact Us Page, you acknowledge that you have reviewed the CalRx Data Collection/Condition of Use and Privacy Policy Statement.

Please do not include any protected health information, such as your medical diagnosis.

CalRx Resources: Data Collection/Condition of Use and Privacy Policy Statement

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