DAFTAR OBAT FORMULARIUM RS PERSAHABATAN JAKARTA

BERDASARKAN KELAS TERAPI

Kelas terapi, nama generik obat,
Bentuk Sediaan dan kekuatan
Dosis Nama Dagang Keterangan
1. ANALGESIK, ANTI I!ETIK,
ANTI IN"LA#ASI N$N
STE!$ID, ANTII!AI
1.1. Analgesik Narkotik
1. Fentanil
Inj. i.m/i.V
am. !"#$/m% & ml
't'. ! Am.(am )ml
). K*+ein
ta,. 1"m$()"m$
-. M*./in
Inj.i.m/0.'/i.1.(
am. 1"m$/ml
't'. 1"am. & 1ml
ta,. 1"m$(1!m$(-"m$
+*0 2 0t.i & 1"ta,
3. Peti+in
inj.i.m/0.'/i.1. lam,at
am. !"m$/ml & )ml
't'. 1"am
1.%. Analgesik non narkotik
1.).1 Anal$e0i' antii.eti'
-. A0am a0etil 0ali0ilat
ta,. 1""m$.'t'
1",l0 & 1" ta,
ta,. !""m$
't'. 1",l0 & 1"ta,
3. Metami.*n
ta,. !""m$ 4 'l$. 1"""ta,
inj. i.m. )!"m$/ml
't'. 1""am & )ml
't'. )!1ial & 1"ml
!. Pa.a0etam*l
Ta,. !""m$/'l$. 1""ta,
0i.. 1)"n$/!ml( ,tl 2"ml
P.eme+. 1""$ i.m
-"52"6 .e *
P*0t *. !"51""$ i.m
Bila e.l74
D4 O.al -"52"m$ tia jam ma'0
)3"m$/8.
A4 151)

t8 4 -m$/'$/8.
!51"m$/+*0i0/i.m/i.1.
Ini0ial 4 1"51! m$/1)jam 9,a$i :$ ,el7m
e.na8 men+aat te.ai *i*i+;
)"5-"m$/1) jam 9,a$i :$ 07+a8 e.na8
men+aat'an te.ai *l*i+;
D4 !"51""m$/+*0i0/i.m....n. 1 'ali la$i
0eteala8 352 jam
A4 ".!51m$/'$/+*0i0
A4 1!5)!m$/'$/+*0i0( )5- 'ali .<.
D4 !""51"""m$/+*0i0( )5- 'ali .<.
A4 =! t8> )!"5!""m$/+*0i0 )5- 'ali
D4 !""51"""m$/15)?
D4 !""51"""m$/+*0i0/)3jam. Ma'0
1"""m$/+*0i0 3""m$/)3jam
A4 !513 t84 )!"51"""m$/)3jam
A4 1"m$/'$/+*0i0 352'ali
D4 !""51"""m$/352?. Ma'0
3"""m$/)3jam
A4 1"m$/'$/+*0i0/352'ali
Fentan:i Jan
@*+ein K/
M*./in H@I K/
MST @*ntini70 MBF
Pet8i+ine H@I K/
A0et*0al OAB
Re0t*. P.i
A0ilet UA
A0<a.+ia P8l
Antal$in O$,
B:l*mi+en D/j
N*1ami+*n N1
Pi.ami+*n P.a
Ant.ain Int
Pa.a0etam*l OAB
Pam*l Int
Pana+*l Ste.
Fa.ma+*l Fa8
Pa.a0etam*l OAB
Pam*l Int
I4 Anal$e0i' na.'*ti'a 07lemen a+a
ane0te0i .e$i*nal/$ene.ai
Kl4 De.e0i e.na/a0an( t.a7ma 'eala(
0e.an$an a'7t a0ma
P4 5 K*m,ina0i +en$an D.*e.i+*l
5 P*ten0i C"? m*./in
ES4 5 De.e0i e.na/a0an
5 Anti+*t 4 nal*?*n
I4 N:e.i .in$an 0e+an$
ES4 K*n0tia0i 7nt7' ema'aian jan$'a
lama
ES4 De.e0i e.na/a0an
I 4 N:e.i '.*ni'
ES4 K*n0tia0i( na70ea( 1*mit70
Kl4 De.e0i e.na/a0an( *,at5*,at
MAOI( *,at5*,at :an$ ,e'e.ja +i
S707nan S:a.a/ P70at
ES4 De.e0i e.na/a0an
Kl4 5 t7'a' lam,7n$
5 $a0t.*ente.iti0
5 8em*/ili
ES4 5 +*0i0 tin$$i4 0ali0illi0me
5 $an$$7an a$.e$a0i
5 t.*m,*0it 4e.+a.a8an
Kl4 5 ale.$i :.aD*l*n
5 A2PD +e/i0ien0i
ES4 a$.an7l*0iit*0i0
Kl4 en:a'it 8ati/$injal
ES4 +*0i0 tin$$i/jan$'a anjan$
5 8eat*t*'0i'
5 ne/.*t*'0i'
Kelas terapi, nama generik obat,
Bentuk Sediaan dan kekuatan
Dosis Nama Dagang Keterangan
A4 1t8 4 -53'ali/8a.i "(2ml
15-t8 4 -53'ali/8a.i
"(251()ml
D4 !""m$/+*0i0
-'ali .<.
A4 )!m$/'$/)3jam
D4 15- ? !"m$/8a.i
15) am I.1/i.m/0.<
153 07 0e8a.i
D4 aEal !!"m$( lal7 )F!m$ tia C 8a.i
AEal4 -"/2"m$ l.m. +aat +ilanj7t'an
+en$an +*0i0 1!/-"m$ tia 2jam. Ma'0
1)"m$/8.
A4 1"5)"m$/'$/)3jam
D> 1""m$/+*0i0 a+a 8a.i e.tama
+itin$'at'an 0amai -""m$/+*0i0
A4 !51"m$/'$/)3jam
D4 ini0ial )""m$/+*0i0 emeli8a.aan4
1""5)""m$/)3jam
A4 )"m$/'$/8a.i
D4 )""53""m$( -?/8a.i
D4 -?!"m$
41 07. Malam
Pana+*l Ste.
Fama+*l Fa8
Sanm*l D.* San
A0am Me/enamat OAB
P*0tan P/i
Me/inal San
Lai0an Lai
T.ama+*l OAB
G7mat.am P.i
D*lana @*m
D*li'a P8a
D*lana @*m
Int.a+*l INF
T.a+:l Int
T.amal P8l
D*lana @*m
S:n/le? DV
S:n/le? DV
N*1al$in AP
Be1*la< N1l
Rem*ain De?
All*7.in*l OAB
Ben*?7.ia Be.
I07.i' Int
U.i<a P.iH
Eenil,7ta0*n OAB
I,7.*/en OAB
R8ela/en Lai
P.*.i0 P8l
R8ela/en Lai
P.*t0 P8l
P.*/eni+ AP
NaD*1el N1l
P.*/eni+ AP
P.*nal$e0 De?
P.*/e<*m @*m
Kl4 Di0e0ia( a0ma( en:a'it $injal
P4 Hamil( la'ta0i( 70ia H13

t8
ES4 M7al( m7nta8( '*n0tia0i
Kl4 Int*'0i'a0i a'7t
al<*8*l/anal$e0i'/8in*ti'/0i'*t.*i'
ES4 De.e0i e.na/a0an( 0e+a0i( m7al(
m7nta8( m7l7t 'e.in$
Kl4 Ul'70 eti'7m( 8amil( la'ta0i
P4 Ji'a 'li.eni0 '.eatinin H)"
ES4 $an$$7an en<e.naan( 0a'it 'eala(
m7al( 1e.ti$*
I4 Te.ai jan$'a en+e' 7nt7' n:e.i a'7t
,e.at
Kl4 Hie.0en0iti/( 7l'70 eti'7m(
$an$$7an $injal( la'ta0i( e.0alinan
P4 Hie.ten0i/'*n+i0i :an$ ,e.87,7n$an
+en$an .eten0i <ai.an( +i0/7n$0i 8ati
ana' H12 t8
Kl4 Se.an$an a'7t A*7t( 8amil( la'ta0i
P4 Di0/7n$0i $injal
ES4 Aan$$7an en<e.naan( 0a'it 'eala
Kl4 Ul'70 eti'7m( en:a'it ti.*i+(
@VD( .iEa:at ale.$i a0i.in
ES4 Aan$$7an en<e.naan( 8eatiti0
Kl4 Sen0iti/ te.8a+a a0i.in( la'ta0i
P4 Ke8amilan( a0ien t7a( $a$al $injal(
a0ma( 7l'70 eti'7m
Kl4 Ul'70 eti'7m
P4 Aa$al $injal
Kelas terapi, nama generik obat,
Bentuk Sediaan dan kekuatan
Dosis Nama Dagang Keterangan
!. Di'l*/ena' nat.i7m9I;
ta,. Sal7t )!m$( !"m$
2. Di'l*/ena' Kali7m9I;
ta,. )!m$( !"m$
't'. !"60
F. Pi.*'0i'am9I;
'a. 1"m$( )"m$
't'. 1" 0t. & 1" 'a
Ael "(!J t7,. 1!$( )!$
C. Ten*'0i'am9I;
ta,. Sal7t )"m$
K. Mel*'0i'am9I;
ta,. F(!m$( 1!m$
't'. )0t. & 1"60
1". K*m,ina0i
K*n+.*itin 07l/at 3""m$(
$l7'*0an( in !""m$
MSM )""m$( Vit @ !"#( M$
$l:<e.*8*08at 1"m$ 'al.
Sal. Sala7t
11. Al7'*0amin S7l/at
K.im 1"J( F!$
1). S7l/a0alaDin9I;
ta,. !""m$
't'. 1"0t. & 1"60
1-. Tin*.i+in H@l9I;
'a. !"m$( 't'. 2"60
D4 - ? )!5!"m$/+*0i0
D4 *le0'an -53'ali/8a.i
D4 1""51!"m$/8a.i
D4
5 O0te*a.t.i0ti0( a.t.iti0 .emat*i+
1?)"m$/8a.i
5 Aan$$7an *t*t 0'elet a'7t
1?3"m$/8a.i
Pa+a 8a.i I +an II( 'm+ 1?)"m$/8a.i(
!51)8a.i
5 A*7t4 1?3" m$/8a.i 0elama 3528a.i
D4 7nt7' 8a0il :an$ e/e'ti/ - ata7 3 8a.i
0e8a.i
D4 Ole0'an -53'ali/8a.i
D4 1 ? )"m$
O0te*a.t.i0ti0 4 F(!m$/8a.i
Remat*i+ a.t.iti0 4 1!m$
Te.ai BB=!!'$ -?1 'al/8a.i( H!!'$
)?1 'al/8a.i emeli8a.aan 1 'a/8a.i
A7na'an 15)? 0e8a.i a+a 0en+i :an$
0a'it
D4 min$$7 I malam 1 ta, lal7 )?1ta,
15)'a/-?/8a.i
Nat.i7m +i'li/ena' OAB
Del/iamat Al
V*lta.en N*1
V*lta+e? De?
V*lta.en N*1
Kali7m +i'l*/ena' OAB
@ata/lam N*1
S<ana/lam TSP
Pi.*'0i'am OAB
Pi.*/el San
S<an+ene TSP
Fel+ene Ael P/i
T8enil Int
Mel*'0i'am OAB
M*1i5<*? BI
A.t.il*? @*m
Me1il*? Be.
O0te*'*m Lai
Me+i/le? Kal
S7l<*l*n Be.
LaDa/in N1l
N*n/lamin Ta'
Kl4 Ul'70 eti'7m
P4 La'ta0i( 'e8amilan
ES4 Aan$$7an en<e.naan( +iDDine00
1e.ti$*
P4 Han:a +i$7na'an a+a e.m7'aan
'7lit :an$ 7t78/0e8at( 8in+a.i '*nta'
+en$an mata +an 0ela7t len+e..
Jan$an +i,e.i'an ,e.0ama 0e+iaan
*.al.
Kl4 Ul'70 eti'7m
P4 La'ta0i( 'e8amilan
ES4 Aan$$7an en<e.naan( +iDDine00
1e.ti$*
Kl4 Ul'70 eti'7m
P4 Aan$$7an '*.+i*1a0'7le.( $a$al
$injal( 'e8amilan
ES4 Aan$$7an en<e.naan
P4 Hin+a.i '*nta' +en$an mata( m7.'*0a
ata7 le0i '7lit te.,7'a
Kl4 Aan$$7an en<e.naan
P4 Aa$al $injal( 0i.*0i0 8ati( en:a'it
jant7n$ '*n$e0ti/
ES4 Aan$$7an /7n$0i $injal/8ati(
+iDDine00
Kl4 Hie.0en0iti/ t8+ a0i.in( AINS :an$
lain( en:a'it $injal ,e.at( 8amil +an
la'ta0i( ana' t7'a' lam,7n$( $a$al
$injal( n*n +ial:0i0 ,e.at( en+a.a8an
0al7.an <e.na +an 0e.e,.*1a0'7le.
I4 O0te*a.t.iti0( 7nt7' memeli8a.a
'e0e8atan 0en+i
I4 Me.e+a8'an n:e.i a+a a.t.iti0 +an
n:e.i 7n$$7n$( n:e.i le8e.( n:e.i
l7t7t +an t7n$'ai( n:e.i e.$elan$an
+an ja.i tan$an
I4 Pe.a+an$an a0<a ,e+a8( <e+e.a
0al7.an 'emi8( *titi0 a.t.iti0(
ei+i+imiti0( l7m,a$*( a.t.al$ia( n:e.i(
7n$$7n$( n:e.i 0etela8 <a,7t $i$i(
.emati'
Kelas terapi, nama generik obat,
Bentuk Sediaan dan kekuatan
Dosis Nama Dagang Keterangan
%. ANASTETIK
%.1. Anastesi lo&al
1. B7l1a'ain H@l
Inj. In/ilt.. ".)!J 9H@l;
Kt'. 1 1ial )" mL
Inj. "(!J 9H@l;5$l7'*0a F(!J
Kt' ! am( & 3 mL
). Etil Kl*.i+a
Sem( ,tl. 1"" mL
-. Li+*'ain H@l
inj. In/ilt. 1 J
inj. P. V. )J
't'. 1"" am & ) mL
jeli )J t7,e 1" $
am7l 3J ,tl !" mL90em;
3. K*m,ina0i 4
Li+*'ain )! m$ L
P.il*'ain )! m$
K.im !J( t7, ! $
!. K*m,ina0i
Li+*'ain H@l )" m$L
Eine/.in 1)(! m$
Inj. ) mL
2. Li$n*'ain H@l
Inj. Am. )J & )" mL
Inj. Am. !"" m$/! mL
%.%. Anastesi umum dan oksigen
1. D.*e.i+*l
Am. )(! m$/mL ? ) mL>
Kt' 1" am
). En/l7.an
@ai.an inlan> ,tl )!" mL
-. Hal*tan
@ai.an( ,tl( )!" mL
3. Ketamin H@l
Vial !" m$/mL & 1" mL
1"" m$/mL & 1" mL
!. P.**/*l
Am. 1" m$/mL & )" mL( !" mL
Kt'. ! 1ial
2. O'0i$en
Aa0 +alam ta,7n$
F. Et*mi+at
Inj. )" m$/1" mL( 't'.1" am
C. Dinit.*$en O'0i+a
Aa0 +alam ta,7n$
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
D> *le0'an 0elai0 te,al + '7lit :an$
inta'
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
D4 Unt7' In+7'0i4 N)O L )"J O)
Ma.<ain AG
Ma.<ain !J AG
B7i<ain @la
B7<<ain Be.
Ma.<ain Hea1: !J AG
@8l*.et8:l S.a: D.H
Li+*<ain KF
Li+*<ain OAB
B:l*<aine Jelli AG
B:l*<aine S.a: AG
E0te0ia
T*0: APL
Emia AG
E?t.a<ain S*8*
E?t.a<ain Et8
Pe8a<ain P8a
Li+*<ain <*m OAB
B:l*<a.+ 1 AG
B:l*<a.+ ! AG
De8i+.*,enDi.i+*l Jan
Et8.an A,,
Hal*tan De?
I1ane0 I'a
Ketamin Hamelin @*.n
Ketaje< @la
P.*/*l @la
Sa1*l N1l
F.e0*/*l F.e
Etimi+at Li7.* BB
I4 Ane0te0i 0inal
I4 Ane0te0i e.m7'aan 7nt7' 4
5 m7l7t M 'e.*n$'*n$an
5 $a0t.*inte0tinal ,a$ian ata0
KI4 ,a:i H 1) ,ln( 8ie.0en0iti/
P4 8in+a.i '*nta' +en$an mata +an
mem,.ane m7'*0a( l7'a te.,7'a
I4 ane0te0i l*<al
P4 Hie.ten0i ,e.at( a.te.i*0'le.*ti'(
in+71i0ien0i KV( ,l*' jant7n$
I4 5 P.eme+i'a0i
5 ane0te0i ne7.*leti'a
I4 ane0te0i in8ala0i
I4 ane0te0i in8ala0i
I4 5 Te.7tama 7nt7' ane0te0i a+a ana'
I4 In+7'0i +an emeli8a.aan ame0te0i
7m7m
I4 O,0t.70i jalan na/a0 9emi0ema(
,.*n<8iti0; 7nt7' men<aai in8ala0i H/N
-"J O)
Pa+a .eten0i @O) 9Pne7m*nia( 7+ema
a.7( al1e*liti0 +an 'e$a$alan 0i.'7la0i;
+aat +ia'ai 0amai +en$an 1""J
tetai 8a.70 +i'7.an$i 0e<eat m7n$'in.
Pa+a ,a:i a08:?ia H/N -!J
ES4 De.e0i e.na/a0an a+a '*n0ent.a0i
tin$$i ,ila 1entila0i jele'
P4 8ati58ati te.8a+a 'e,a'a.an
I4 Ane0te0i in8ala0i
K. Se1*/l7.an
@ai.an( ,tl. )!" mL
1". Mi+*D*lam9I;
Inj. I.1. 1 m$/mL(
Kt'( ! am & ! mL
Inj. I.1. ! m$/mL(
Kt'( ! am& !"" m$
11. Nat.i7m Ti*ental
Se.,. Inj. I.1. !"" m$ 9+ila.7t'an
+alam )" m$ ai. inje'0i;
Kt'( 1" am( & !"" m$
1). I0*/l7.ane
@ai.an( ,tl. )!" mL
'. ANTI ALE!GI DAN $BAT
(NT(K ANA"ILAKSIS
1. De'0ameta0*n
Inj. ! m$/mL(
Kt'. 1"" am & 1 mL
Ta, "(! m$( 'l$.1""" ta, 9I;
). Metil .e+ni0*l*n9I;
Ta,. 3 m$( C m$( 12 m$
Kt'( 1" 0t. & 1"60
Inj. 1)! m$/) mL( !"" m$/mL
-. Di/en8i+.amin H@l
Inj. i.m. 1" m$/mL
Kt'. 1"" am & 1 mL
3. Eine/.in 9a+.enalin;
Inj. I.1. "(1J(
Kt'( 1"" am & 1 mL
+ie.ta8an'an +en$an <am7.an -"J
O)
5 Unt7' anal$e0ia a+a *,0tet.i<( !"J
N)O L O)
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
P.*t*'*l '87070
D4 35)"m$/+*0i0 I.m/I.1.( ...n. +i7lan$i
te.$ant7n$ 'e,7t78an
A4 "(15"() m$/'$/+*0i0 I.1
D4 "(!51(! m$/+*0i0
- 'ali/)3 jam
A4 "(- m$/'$/+*0i0
- 'ali/)3 jam
D4 Pe.m7laan4
353C m$ 0e8a.i
Pemeli8a.aan4
3512 m$/8a.i
D4 1"5)" m$/+*0i0 I.m/I.1.
-53 'ali/)3 jam
D4 "(- m$/+*0i0/0.'
A4 "("1 m$/'$/+*0i0
0.'> ...n. -?/ 1! menit
Se1*/l7.ane A,,
Mil*D N1l
Mi+aD*lam Hamein @*m
SeD*lam @la
I0*/l7.ane De?
F*.ane A,,
De'0ameta0*n OAB
Kalmeta0*n Kal
De'0ameta0*n OAB
Kalmeta0*n Kal
In+e?*n Int
Metil P.e+ni0*l*n OAB
Lame0*n Lai
Met8:l*n Be.
Inti+.*l Int
Me+i?*n De?
Met8:l*n Be.
R8in*/e+ De?
I'a+.:l inj I'a
Pa.a+.:l P.a
Eine8.ine OAB
A+.enalin et8
ES4 ema'aian jan$'a anjan$ +aat
men:e,a,'an +e.e0i 07m07m t7lan$
P4 ma'0im7m )3 jam
I4 ane0te0i in8ala0i
I4 in+7'0i +an emeli8a.aan ane0te0i
l*<al
I4 ane0te0i I.1
I4 ane0te0i in8ala0i 7m7m
KI4 7l'70 eti'7m( H. Simle' *<7la.(
in/e'0i jam7. 0i0temi'.
P4 Hi*ti.*i+( 0i.*0i0 8ati( 8ie.ten0i(
DM( @HF
ES4 lema8( *0te**.*0i0( $an$$7an
men0( .eten0i <ai.an M ele't.*lit(
en+a.a8an lam,7n$( m**n/a<e
I4 A.t.iti0 Remat*i+( ,7.0iti0 a'7t/ 07,
a'7t. De.matiti0 e'0/*liti1a( .8initi0
ale.$i( a0ma ,.*n<8ial( +e.matiti0
'*nta'( '*nj7n$ti1ita0 ale.$i
KI4 In/e'0i jam7. 0i0temi'( im7ni0a0i
ES4 Reten0i NA M <ai.an( lema8 *t*t(
*0te**.*0i0( $an$$7an en:em,78an
l7'a( $an$$7an meta,*li0me
ES4 5 men$at7'
5 +*0i0 tin$$i> 'ejan$5'ejan$ a+a
en+e.ita eile0i
I4 a0ma( an$i*ne7.*ti' e+ema(
$la7<*ma( 0:*' ale.$i
KI4 in07/i0ien0i '*.*ne.( 0:*' 0aat
*e.a0i 'e.70a'an *ta' *.$ani<
P4 8ie.ten0i( DM
ES4 0a'it 'eala( $an$$7an en<e.naan(
ta'i'a.+i( ,in$7n$( +an +e.e0i
e.na/a0an/SSP