IVIg Utilization Management Program Recommendations

Jul 2019

IVIg Request Process 

TMS IVIg Screening Request Form

For centralized screening of IVIg for all Adult Rheumatology conditions, and Neurology conditions as per the Neurology program guidelines

Peripheral Nervous System Conditions: IVIg Outcome Questionnaire

To be used for Non-Approved Peripheral Nervous System conditions only.

Sep 2022

Central Nervous System Conditions: IVIg Outcome Questionnaire

To be used for Central Nervous System conditions only.

Sep 2022

Rheumatology Conditions: IVIg Outcome Questionnaire

To be used for Adult Rheumatology conditions only.

Secondary Immunodeficiency Ig NEW Request Template

To be used as a template for Health Authorities to create their specific SID Ig order form. 

Secondary Immunodeficiency Ig RENEWAL Request Template

To be used as a template for Health Authorities to create their specific SID Ig order form. 

Physician's Order for IVIg Template

To be used as a physician’s order form template for IVIg at the Health Authority. Conditions listed are approved for use of IVIg in BC.

Physician's Order for IVIg Template - Neurology 

To be used as an order form template for IVIg, for Health Authority Physicians.

 Jun 2022

IVIG Hemolysis Letter Template

Can be used as a communication tool to explain the risk of hemolysis in high dose IVIg therapy in group A, B, and AB patients.