Pa. Code tit. 31, pt. IV, ch. 89, subch. M, app H
Immunizing Agents and Doses
Under § 89.807(b) (relating to immunizing agents, doses and AWPs), the Department of Health has established a table setting forth immunizing agent and dose information extracted from recommendations of the Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention, United States Department of Health and Human Services. The relevant ACIP recommendations are those which prescribe child immunization practices and are currently in effect. The child immunization practices specified in those recommendations are subject to the insurance coverage required by the Childhood Immunization Insurance Act (act) (40 P. S. §§ 3501-3508) as explained in § 89.806(a) (relating to coverage of child immunizations).
Under § 89.807(b), the Department of Health is to also periodically publish a notice in the Pennsylvania Bulletin setting forth the AWPs for dosage units of immunizing agents which the relevant ACIP recommendations prescribe for use in child immunizations. The AWPs are calculated as described in § 89.807(a) and should be recalculated monthly as explained in that subsection.
The immunizing agent and dose information is set forth in this appendix. This information is subject to change. It may be superseded, as explained in §§ 89.806(a) and 89.807(a).
The Department of Health will arrange for an update notice to appear in the Pennsylvania Bulletin within 30 days after a new ACIP recommendation which satisfies the standards in § 89.806(a) is published in the Morbidity and Mortality Weekly Report, a weekly publication of the United States Department of Health and Human Services. The new recommendations will be codified in this appendix.
2011 List of Immunizing Agents and Average Wholesale Prices
| Product Name, Company | Brand/Product Name | NDC Number | Unit | Dose | AWP/Dose* |
| Diphtheria Tetanus acellular Pertussis Vaccine (DTaP): | |||||
| sanofi Pasteur | Tripedia | 49281-0298-10 | 10 x 1 | 0.5 ml | $27.97 |
| sanofi pasteur | Daptacel | 49281-0286-10 | 10 x 1 | 0.5 ml | $28.83 |
| GlaxoSmithKline | Infanrix-syringe | 58160-0812-46 | 10 x 1 | 0.5 ml | $23.02 |
| GlaxoSmithKline | Infanrix | 58160-0810-11 | 10 x 1 | 0.5 ml | $24.70 |
| Tetanus Diphtheria acellular Pertussis Vaccine (TdaP): | |||||
| sanofi pasteur | Adacel | 49281-0400-10 | 10 x 1 | 0.5 ml | $46.15 |
| sanofi pasteur | Adacel | 49281-0400-15 | 5 x 1 | 0.5 ml | $46.15 |
| GlaxoSmithKline | Boostrix | 58160-0842-11 | 10 x 1 | 0.5 ml | $44.61 |
| GlaxoSmithKline | Boostrix-syringe | 58160-0842-51 | 10 x 1 | 0.5 ml | $44.61 |
| Diphtheria Tetanus pediatric Vaccine (DT pediatric): | |||||
| sanofi pasteur | DT Pediatric | 49281-0278-10 | 10 x 1 | 0.5 ml | $37.27 |
| Diphtheria Tetanus acellular Pertussis/Haemophilus Influenzae B (DTaP-HIB): | |||||
| sanofi pasteur | TriHIBit | 49281-0597-05 | 5 x 1 | 0.5 ml | $56.58 |
| Tetanus Diphtheria adult Vaccine (Td adult): | |||||
| sanofi pasteur | Decavac | 49281-0291-83 | 10 x 1 | 0.5 ml | $24.17 |
| sanofi pasteur | Decavac | 49281-0291-10 | 10 x 1 | 0.5 ml | $24.17 |
| Merck & Co. | Td Vaccine | 14362-0111-03 | 10 x 1 | 0.5 ml | $22.34 |
| Diphtheria, Tetanus, acellular Pertussis, Haemophilus Influenzae B, Polio (DTaP, HIB, IPV): | |||||
| sanofi pasteur | Pentacel | 49281-0510-05 | 5 x 1 | 0.5 ml | $92.22 |
| Diphtheria, Tetanus, acellular Pertussis, Polio (DTap, IPV): | |||||
| GlaxoSmithKline | Kinrix-syringe | 58160-0812-51 | 10 x 1 | 0.5 ml | $57.00 |
| GlaxoSmithKline | Kinrix | 58160-0812-11 | 10 x 1 | 0.5 ml | $57.00 |
| Diphtheria, Tetanus, acellular Pertussis, Hepatitis B, Polio (DTaP, Hep B, IPV): | |||||
| GlaxoSmithKline | Pediarix | 58160-0811-11 | 10 x 1 | 0.5 ml | $84.12 |
| GlaxoSmithKline | Pediarix-syringe | 58160-0811-46 | 5 x 1 | 0.5 ml | $84.12 |
| Tetanus Toxoid: | |||||
| sanofi pasteur | Tetanus toxoid | 49281-0820-10 | 10 x 1 | 0.5 ml | $37.03 |
| Haemophilus Influenzae Type B Vaccine (HIB): | |||||
| sanofi pasteur | ActHIB | 49281-0545-05 | 5 x 1 | 10 mcg | $29.00 |
| Merck & Co. | Pedvax HIB | 00006-4897-00 | 10 x 1 | 7.5 mcg | $27.32 |
| GlaxoSmithKline | Hiberix | 58160-0806-05 | 10 x 1 | 0.5 ml | $8.66 |
| Injectable Polio Vaccine Inactivated (Salk Enhanced IPV): | |||||
| sanofi pasteur | IPOL | 49281-0860-55 | 10 x 1 | 0.5 ml | $30.36 |
| sanofi pasteur | IPOL | 49281-0860-10 | 5.0 ml | 0.5 ml | $30.36 |
| Measles Mumps Rubella Vaccine (MMR): | |||||
| Merck & Co. | MMR II | 00006-4681-00 | 10 x 0.5 | 0.5 ml | $55.40 |
| Measles Vaccine (Rubeola): | |||||
| Merck & Co. | Attenuvax | 0006-4589-00 | 10 x 0.5 | 0.5 ml | $20.48 |
| Meningococcal Conjugate Vaccine (MCV4): | |||||
| sanofi pasteur | Menactra | 49281-0589-05 | 5 x 1 | 0.5 ml | $127.64 |
| sanofi pasteur | Menactra | 49281-0589-15 | 5 x 1 | 0.5 ml | $127.64 |
| Novartis | Menveo | 46028-0208-01 | 5 x 1 | 0.5 ml | $106.49 |
| Meningococcal Polysaccharide Vaccine: | |||||
| sanofi pasteur | Menomune-A/C/Y/W-135 | 49281-0489-91 | 10 x 1 | 0.5 ml | $130.11 |
| sanofi pasteur | Menomune-A/C/Y/W-135 | 49281-0489-01 | each | 0.5 ml | $130.11 |
| Mumps Vaccine: | |||||
| Merck & Co. | Mumpsvax | 00006-4584-00 | 10 x 0.5 | 0.5 ml | $26.54 |
| Rubella Vaccine: | |||||
| Merck & Co. | Meruvax II | 00006-4673-00 | 10 x 0.5 | 0.5 ml | $22.83 |
| Hepatitis A Vaccine (HEP-A): | |||||
| Merck & Co. | VAQTA-syringe | 00006-4096-31 | 1.0 ml | 1.0 ml | $77.89 |
| Merck & Co. | VAQTA-syringe | 00006-4096-06 | 6 x 1 | 1.0 ml | $77.87 |
| Merck & Co. | VAQTA | 00006-4841-00 | 1.0 ml | 1.0 ml | $76.21 |
| Merck & Co. | VAQTA | 00006-4841-41 | 10 x 1 | 1.0 ml | $71.99 |
| Merck & Co. | VAQTA Pediatric | 00006-4831-41 | 10 x 0.5 | 0.5 ml | $36.44 |
| GlaxoSmithKline | Havrix Ped-syringe | 58160-0825-52 | 10 x 1 | 0.5 ml | $34.34 |
| GlaxoSmithKline | Havrix Pediatric | 58160-0825-11 | 10 x 1 | 0.5 ml | $34.34 |
| GlaxoSmithKline | Havrix-syringe | 58160-0826-46 | 5 x 1 | 1 ml | $72.68 |
| GlaxoSmithKline | Havrix | 58160-0826-11 | 10 x 1 | 1 ml | $72.68 |
| Varicella Virus Vaccine: | |||||
| Merck & Co. | Varivax | 00006-4826-00 | each | 0.5 ml | $105.29 |
| Merck & Co. | Varivax | 00006-4827-00 | 10 x 1 | 0.5 ml | $100.38 |
| Merck & Co. | Zostavax | 00006-4963-00 | each | 19400 pfu | $193.80 |
| Merck & Co. | Zostavax | 00006-4963-41 | 10 x 1 | 19400 pfu | $184.72 |
| Human Papilloma Virus Vaccine: | |||||
| Merck & Co. | Gardasil | 00006-4045-00 | each | 0.5 ml | $156.50 |
| Merck & Co. | Gardasil | 00006-4045-41 | 10 x 1 | 0.5 ml | $156.18 |
| Merck & Co. | Gardasil-syringe | 00006-4109-06 | 6 x 1 | 0.5 ml | $158.00 |
| Merck & Co | Gardasil-syringe w/o needle | 00006-4109-09 | 6 x 1 | 0.5 ml | $158.00 |
| GlaxoSmithKline | Cervarix | 58160-0830-11 | 10 x 1 | 0.5 ml | $128.75 |
| GlaxoSmithKline | Cervarix-syringe | 58160-0830-46 | 5 x 1 | 0.5 ml | $128.75 |
| Rotavirus Vaccine: | |||||
| Merck & Co. | Rotateq | 00006-4047-41 | 10 x 1 | 2 ml | $83.35 |
| GlaxoSmithKline | Rotarix | 58160-0805-11 | 10 x 1 | 1.0 ml | $122.85 |
| Influenza Virus Vaccine: | |||||
| Novartis | Fluvirin | 66521-113-02 | 10 x 1 | 0.5 ml | $18.24 |
| Novartis | Fluvirin | 66521-113-10 | 10 x 1 | 0.5 ml | $14.81 |
| Sanofi pasteur | Fluzone | 49281-0011-10 | 10 x 1 | 0.5 ml | $15.58 |
| Sanofi pasteur | Fluzone | 49281-0011-50 | 10 x 1 | 0.5 ml | $15.58 |
| Sanofi pasteur | Fluzone | 49281-0388-15 | 10 x 1 | 0.5 ml | $14.01 |
| Sanofi pasteur | Fluzone Pediatric | 49281-0111-25 | 10 x 1 | 0.25 ml | $16.53 |
| GlaxoSmithKline | Fluarix | 58160-0873-46 | 5 x 1 | 0.5 ml | $15.75 |
| MedImmune | Flumist | 66019-0108-10 | 10 x 1 | 0.2 ml | $22.31 |
| Merck & Co. | Afluria | 33332-0010-01 | 10 x 1 | 0.5 ml | $13.05 |
| Merck & Co. | Afluria | 33332-0111-10 | Multidose | 0.5 ml | $12.15 |
| Hepatitis B Vaccine (HEP-B): | |||||
| Merck & Co. | Recombivax HBHepatitis B vaccine (Recombinant) Dialysis Formulation | 00006-4992-00 | each | 1.0 ml | $165.29 |
| Merck & Co. | Recombivax HB Pediatric | 00006-4981-00 | 10 x 0.5 ml | 0.5 ml | $27.85 |
| Merck & Co. | Recombivax HB | 00006-4995-00 | 1.0 ml | 1.0 ml | $71.64 |
| Merck & Co. | Recombivax HB | 00006-4995-41 | 10 x 1.0 ml | 1.0 ml | $70.81 |
| Merck & Co. | Recombivax HB syringe | 00006-4094-31 | 1.0 ml | 1.0 ml | $73.31 |
| Merck & Co. | Recombivax HB syringe | 00006-4094-06 | 6 x 1.0 ml | 1.0 ml | $73.31 |
| Merck & Co | Recombivax HB syringe w/o needle | 00006-4094-09 | 6 x 1.0 ml | 1.0 ml | $73.31 |
| GlaxoSmithKline | Engerix-B Pediatric | 58160-0820-11 | 10 x 1 | 0.5 ml | $25.49 |
| GlaxoSmithKline | Engerix-B Pediatric | 58160-0820-46 | 5 x 1 | 0.5 ml | $25.49 |
| GlaxoSmithKline | Engerix-B Pediatric | 58160-0856-35 | 5 x 1 | 0.5 ml | $25.49 |
| GlaxoSmithKline | Engerix-B syringe | 58160-0821-51 | 10 x 1 | 1.0 ml | $62.85 |
| GlaxoSmithKline | Engerix-B syringe | 58160-0821-11 | 10 x 1 | 1.0 ml | $62.85 |
| Hepatitis B / HIB: | |||||
| Merck & Co. | COMVAX | 00006-4898-00 | 10 x 0.5 ml | 0.5 ml | $52.27 |
| Hepatitis A & Hepatitis B Vaccine: | |||||
| GlaxoSmithKline | Twinrix | 58160-0815-11 | 10 x 1.0 | 1.0 ml | $103.43 |
| GlaxoSmithKline | Twinrix-syringe | 58160-0815-46 | 5 x 1.0 | 1.0 ml | $103.43 |
| Pneumococcal Vaccine: | |||||
| Pfizer | Prevnar 13 | 0005-1971-02 | 10 x 1 | 0.5 ml | $141.75 |
| Merck & Co. | Pneumovax 23 | 00006-4739-00 | 2.5 ml | 0.5 ml | $60.20 |
| Merck & Co. | Pneumovax 23 | 00006-4943-00 | 10 x 1 | 0.5 ml | $67.58 |
| Measles, Mumps, Rubella, and Varicella Vaccine | |||||
| Merck & Co. | ProQuad | 00006-4999-00 | 10 x 0.5 | 0.5 ml | $160.12 |
Pa. Code tit. 31, pt. IV, ch. 89, subch. M, app H