Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter M - Reserved › Appendix H - Immunizing Agents and Doses

Current through Register Vol. 54, No. 28, July 13, 2024
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 It may be superseded, as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