iCare+ Weight Loss Clinic Onboarding Form

Pharmacy Profile

Please answer the following:

One form must be completed for each participating pharmacy location. Expect a processing time of up to 2 weeks.

To participate in the iCare+ Weight Loss Program you acknowledge the following:

1. You must be enrolled into the iCare+ Virtual Healthcare Program, complete the onboarding form and execute the program acknowledgement agreement. If you are already participating, please ignore!

2. This onboarding form must be thoroughly completed

3. You must be promoting weight loss education

4. You must be dispensing Semaglutide compounds from your store. (Ex. The compound cannot be shipped from another store to your patient. The other store can deliver the Semaglutide to you.)

5. Patients must receive program guidance from you in accordance with the patient protocol and contradictions disclosed in this onboarding form.

Participation in the iCare+ Weight Loss Clinic is available only where permitted by your state board of pharmacy. Please ensure compliance with your state's pharmacy regulations before participating.

Do you know your IPC account number?*

If you do not know your IPC Account Number, please call IPC at 608-478-1099 or email us at member.service@ipcrx.com

Yes

Pharmacy Name*

What is the exact name of your stores that consumers/patients recognize (fill)?

Primary Contact for Semaglutide only:

First Name*

Last Name*

Email*

You will receive all email communications as the primary contact of your pharmacy.

Store Telephone Number*

Store Fax Number*

Street Address of Participating Site*

Street Address Line 2

City (Participating Site)*

State/Province (Participating Site)*

Postal Zip Code*

Drug and dose (injection)

Concentration

Vial Size

Vial Quantity

Additional ingredient

Additional Instructions

Ex Semaglutide 0.25mg

Ex: Cyanocobolamin

What is your pharmacy's compounding designation?*

503A

503B

Neither

Are you compounding GLP-1 medications in your pharmacy or sourcing from a 503B facility?*

I am compounding in my pharmacy.

I am sourcing compounded medications from a 503B facility.

Neither

Do you have an existing therapy program designed around the compounded product?*

Yes

Please describe if you answered "Yes" to the previous question (ex. weight loss and specify how it works inside your store)*

Have there been any complaints or disciplinary actions against the pharmacy?*

Yes

If you answered "Yes" to the previous question, please explain:*

Does the pharmacy have a state board inspection report for review?*

Yes

If you answered "Yes" to the previous question, please provide documentation:

Upload

Is the pharmacy accredited by the Pharmacy Compounding Accreditation Board?*

Yes

If you answered "Yes" to the previous question, please provide documentation

Upload

Are you USP 800-compliant, USP 797-compliant, or neither?*

USP 800-compliant

USP 797-compliant

Neither

Where does your pharmacy source the active pharmaceutical ingredient? *

Please leave this answer blank if you are not currently offering a compounding program.

Is your supplier registered with the FDA?*

Yes

Unsure

If you answered "Yes" to the previous question, please provide documentation:

Upload

Is the compounded drug being made differently than the commercially available product?*

Yes

Please explain if you answered "Yes" to the previous question:*

Is the pharmacy using Semaglutide base, not Semaglutide salt, in the compounding process?*

Yes

Does the pharmacy have a certificate of analysis (COA) of the active pharmaceutical ingredient, which should be Semaglutide base? *

Yes

If you answered "Yes" to the previous question, please provide documentation:

Upload

Does the pharmacy have third-party confirmation of potency, stability, and sterility testing of the final product? *

Yes

If you answered "Yes" to the previous question, please provide documentation:

Upload

Which form will the pharmacy be providing?*

Oral

Injection

Both

What doses are you going to prescribe for each form and EXACTLY how do you want each prescription written so we can customize a prescription template for each dose? Use the template below:

To fill in the tables below, please click here to download our template and remember to upload your completed template using the upload link.

The template should look as such:

*Drug and dose (Oral)*	*Form (tab/troche)*	*quantity*	*Sig:*	*Additional instructions*

Do you require a prescription for supplies? If so please provide exact rx below.

Supplies	Syringes type	Quantity	Refills

Ex: U100 1/2ml/cc 29G Syringe 5/16" (*mm) Needles #10/25days. #10. No refills

Please upload the completed spreadsheet in .xlsx format.*

Upload here.

Different or Same Vial Sizes*

Different

Same

If you answered "Different" to the previous question, please provide an explanation:*

Do the patients you service have access to a Quest Diagnostics within 50 miles of your store?

Please click here for a Quest Diagnostics lab locator.

Yes

PROGRAM DISCLOSURES

Patient Protocol

BMI Requirements for Potential Patients:

DQ: BMI <27

BMI: 27-29 plus 1 comorbid condition

BMI: 30< with no comorbid conditions

Patients with a BMI of 27-30 with no comorbid conditions may still qualify. This will be handled on a case-by-case basis. Consider for patients who are wanting to lose 20 or more pounds

Contraindications (not accepted into the program)

Women who are breast feeding, pregnant or who plan to become pregnant within the next year.
Personal History of Medullary Thyroid Cancer
Family History of Medullary Thyroid Cancer. Note: must be able to provide information on type if any thyroid cancer history present.
Multiple Endocrine Neoplasm 2a and 2b
DM Type 1
DM Type 2 with Diabetic Retinopathy, insulin dependence or use of sulfonylureas. Sulfonylureas Include: Amaryl, cholopropamide, Diabeta, Diabinese, glimepiride, glipizide, glucotrol, Glucotrol XL, glyburide, glynase, glyase presTab, Minodiab, Orinase, Tolazamide, Tolbutamide, Tolinase.
Undergoing dialysis
Stroke
Heart failure
Hypertension on more than 2 blood pressure medications.
Myocardial infarction (heart attack) or history of CAD, Stent placement, cardiac bypass
Organ transplant
Active cancer undergoing treatment (such as chemotherapy, radiation, etc.)
Suicide attempts or ideation
Anorexia or bulimia or other eating disorders.
Liver failure/chronic liver disease
Active Pancreatitis or gallbladder disease
Age greater than 75.
Age less than 18

Labs will not be required to start the program but will be required by the first refill appointment and include the following:

Lipid Panel (Fasting)
CMP
TSH
HgA1c
Urine Preg or blood test: Not required but consider if reason for concern. May ask pt to follow up with PCP for testing.
CBC-not required but consider if reason for concern

Labs will be ordered at the first visit and will be required to be completed by the first follow up visit.

Abnormal Labs: Members with abnormal labs prior to beginning medications will be reviewed case by case.

Follow Up Labs: Labs will be repeated every 180 days or sooner if needed. Labs should include a CMP, CBC, amylase and lipase, HgB A1C, lipids, and TSH.

The contents provided is confidential, please do not discuss the nature of this program outside the IPC Digital Health and iCare+ Development and Test teams. All results are confidential including issues that may surface during and post process.

Follow Up Appointments:

Members will follow up within 3 weeks upon implementation of medication therapy via sync/async appt. Appointment type will be determined by side effects. Member will follow up PRN for any signs or symptoms of infection from the injection site, moderate side effects, or any other medical questions.

Continued follow up every 30 days until medication is discontinued. The first visit will be synchronous. Each subsequent visit can be asynchronous or synchronous unless there are symptoms that need to be reviewed. Side effects or lack of sufficient weight loss should be reviewed with a synchronous visit. The patient should have a face to face visit every 4-6 months.

For patients taking compounded GLP-1 medications monitor for pancreatitis and gallbladder disease at every visit.

Independent Pharmacy Cooperative (IPC) and its subsidiary IPC Digital Health, LLC., owner of the iCare+ brand, are not responsible for any aspects of the Pharmacy GLP-1 Program or Medication Compounding Program, including, but not limited to, the preparation, dispensing, or administration of any medications. By participating in these programs, you acknowledge and agree that the pharmacy or healthcare provider administering these treatments is solely responsible for ensuring their safety, efficacy, and compliance with all applicable laws and regulations.

The Company disclaims any liability for any adverse effects, complications, or other issues that may arise in connection with participation in these programs. You should consult with a qualified healthcare professional before starting or making any changes to your treatment regimen. IPC and IPC Digital Health shall not be held responsible for any damages, injuries, or claims arising from your involvement in these programs.