Q1: Are your out-of-pocket medical costs* unreasonable? *

*Out-of-pocket costs include deductibles, coinsurance, co-pays for covered service, as well as cash pay healthcare costs for services that aren't covered by insurance.

Yes

No

Q2: Have you or a family member/loved one ever benefited from a new medicine or treatment like an immunotherapy or targeted gene and cell therapies? *

Yes

No

I don't know

Q3: Have you or a family member/loved one ever faced challenges with insurance coverage for new or innovative treatments? *

Yes

No

Were you eventually successful in securing coverage?

Yes

No

How much time did you spend attempting to resolve/appeal the issue with your insurance before abandoning your efforts?

Days

Weeks

Months

Years

Q5: Are you willing to share your story publicly to advocate for policy changes? *

Yes

No, I wish to remain anonymous

Phone

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Name

First Name

Last Name