Appendix 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 It may be superseded, as explained in § § 89.806(a) and 89.807(a).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

Source

The provisions of this Appendix H adopted February 3, 1995, effective February 4, 1995, 25 Pa.B. 511; amended August 16, 1996, effective August 17, 1996, 26 Pa.B. 3958; amended August 10, 2001, effective August 11, 2001, 31 Pa.B. 4498; amended October 25, 2002, effective October 26, 2002, 32 Pa.B. 5352; amended March 14, 2003, effective March 15, 2003, 33 Pa.B. 1418; amended April 16, 2004, effective April 17, 2004, 34 Pa.B. 2135; amended September 16, 2005, effective September 17, 2005, 35 Pa.B. 5190; amended January 19, 2007, effective January 20, 2007, 37 Pa.B. 372; amended December 21, 2007, effective December 22, 2007, 37 Pa.B. 6851; amended February 27, 2009, effective February 28, 2009, 39 Pa.B. 1167; amended February 5, 2010, effective February 6, 2010, 40 Pa.B. 760; amended September 17, 2010, effective September 18, 2010, 40 Pa.B. 5404; amended March 4, 2011, effective March 5, 2011, 41 Pa.B. 1263; amended October 28, 2011, effective October 29, 2011, 41 Pa.B. 5821. Immediately preceding text appears at serial pages (356175) to (356181).

Cross References

This appendix cited in 31 Pa. Code § 89.807 (relating to immunizing agents, doses and AWPs).