SHARE YOUR STORY: How will lower Rx prices impact you?

Do you take prescription medications?

Yes

No

No, but someone in my family does

How do high medicine costs hurt you or your family? (Your answer might be shared to help others.)

How would cheaper medicine make life better for you or your family? Please give details. (Your answer might be shared.)

Do you use any of these drugs that Medicare is working to make cheaper? (Check all that apply)

Eliquis

Jardiance

Xarelto

Januvia

Farxiga

Entresto

Enbrel

Imbruvica

Stelara

Fiasp/NovoLog

Other

About how much do you pay out-of-pocket for Eliquis per month?

About how much do you pay out-of-pocket for Jardiance per month?

About how much do you pay out-of-pocket for Xarelto per month?

About how much do you pay out-of-pocket for Januvia per month?

About how much do you pay out-of-pocket for Farxiga per month?

About how much do you pay out-of-pocket for Entresto per month?

About how much do you pay out-of-pocket for Enbrel per month?

About how much do you pay out-of-pocket for Imbruvica per month?

About how much do you pay out-of-pocket for Stelara per month?

About how much do you pay out-of-pocket for Fiasp/NovoLog per month?

If you take a different drug that is extremely expensive, feel free to write it in here.

Are you currently benefiting from $35/month insulin?

Yes

No

About how much do you pay out-of-pocket for for it per month?

OPTIONAL: What has the insulin price cap meant to you? Share your story publicly (describe the before and after):

Do you expect to benefit from the Medicare $2,000/month cap on out-of-pocket costs?

Yes

No

Optional: What will the $2,000 out-of-pocket cap mean to you? Share your story publicly (describe the before and after):

Would you be okay talking to a journalist or speaking at an event?

Yes

No

Maybe

What is your mobile phone number so we can give you the details?

Can you tell us a little about yourself?

Have you ever spoken with reporters or at a media event?

Yes

No

Can you briefly say what the issue was and what your experience was like?

How have you been affected by high prescription drug prices?

Answer here: