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Prescription Drug Affordability Board

Report an Affordability Issue

Instructions

  • The Prescription Drug Affordability Board (PDAB) encourages individuals to report drug price increases and affordability issues with prescription drugs.
  • These forms will be used to gather information to assist the Board in identifying prescription drugs to study and to connect PDAB with members of the public who would like assistance in affording their drug.
  • Each form is for one specific drug. You may submit multiple forms if you are having affordability challenges with multiple drugs.
  • You may submit the quick submission form or the full submission form as explained below.
  • The PDAB values your experience and insight. 

How to report an affordability issue

  • Option 1: Submit Online

    The PDAB offers two Patient Drug Submission Options.

    • Quick Submission: This is a shortened survey (1 minute) designed to obtain minimal information from consumers experiencing drug affordability issues. This form does not ask for any identifying information.
    • Full Submission: This is a longer survey (5 minutes) designed to obtain more detailed information from consumers experiencing drug affordability issues. Use this form if you would like the PDAB to reach out to you and provide patient assistance. Identifying information is optional in this form.
    Complete the Quick Submission Form Complete the Full Submission Form

  • Option 2: Email

    Email the completed Quick Submission form - PDF - 166.28 KB or Full Submission form - PDF - 147.79 KB to [email protected].

  • Option 3: Mail

    Print the Quick Submission form or Full Submission form and mail to:

    Maryland Prescription Drug Affordability Board

    16900 Science Drive, Suite 112-114

    Bowie, MD 20715

    Patients may also email [email protected] or call PDAB staff (410-702-4981) to have a form sent via USPS.

Disclaimer

Information submitted on this form is a public record subject to disclosure under the Public Information Act (PIA). Certain information including sociological and medical information may be withheld or redacted in compliance with the PIA and applicable regulations.​