USULAN PENGAJUAN OBAT

DANA KAPITASI JAMINAN KESEHATAN NASIONAL (JKN)

OBAT KATAGORI NON E KATALOG
PUSKESMAS PAGADEN TAHUN 2016

JUMLAH
NO NAMA OBAT SATUAN
KEBUTUHAN
1 Aciklovir salep kulit tube 600
2 Ambroxol syr botol 60ml 1200
3 Ambroxol tablet box/10 strip 500
4 Antalgin 500mg tablet box/10 strip 5
5 Antalgin plus box/10 strip 5
6 Bisacodil tablet box/10 strip 5
7 Bromhexin tablet box/10 strip 30
8 Dexchlorpheniramin+Dexametason box/10 strip 600
9 Dexchlorpheniramin maleat 2mg box/10 strip 240
10 Etakridin/Rivanol botol 100ml 0
11 Eugenol botol 10ml 5
12 Famotidin 20mg box/10 strip 5
13 Gentian violet botol 0
14 GG 100mg tablet box/10 strip 1200
15 Glibenclamid box/10 strip 120
16 Griseovulpin 125mg box/10 strip 0
17 Kaolin pectin syr botol 60ml 600
18 Kloramfenicol tts mata plus botol 5ml 600
19 Kloramfenicol tts telingga botol 10ml 600
20 Meloxicam 15mg box/5 strip 500
21 Meloxicam 7,5mg box/5 strip 250
22 Multivitamin tablet box/10 strip 60
23 Natrium Bicarbonat tablet btl/100 tab 10
24 Obat batuk herbal dewasa botol 60ml 600
25 Obat batuk syr+ Paracetamol anak botol 60ml 1262
26 Obat batuk tablet box/10 strip 120
27 Oksitetracyclin salep kulit tube 600
28 Papaverin 40mg box/10 strip 0
29 Piroxicam 10mg box/10 strip 120
30 Piroxicam 20mg box/10 strip 500
31 Simetidin 200mg box/10 strip 5
32 Spongostan box/50pcs 1
33 Thiamfenicol capsul box/10 strip 50
34 Thiamfenicol syr botol 60ml 200
35 Valetamat inj box/10 amp 20
36 Vitamin + Fe box/10 strip 10
37 Vitamin syr botol 60ml 600
Jumlah Total

Subang, Oktober 2
Pengelola Obt Puskesmas

Aan Kusmayanti.S.Si.,Apt dr.Hj. Indiati Oetama

NIP. 19700416 199203 2 006
 T
NASIONAL (JKN)
LOG
2016

HARGA TOTAL
(RP) (RP)
4090 2454000
5150 6180000
19510 9755000
23245 116225
56810 284050
59400 297000
28000 840000
33000 19800000
22000 5280000
2275 0
82500 412500
37500 187500
4150 0
18000 21600000
16450 1974000
37440 0
6890 4134000
21000 12600000
8250 4950000
59950 29975000
34595 8648750
81404 4884240
5800 58000
12100 7260000
8000 10096000
66000 7920000
2475 1485000
30000 0
13105 1572600
16380 8190000
17925 89625
643500 643500
144690 7234500
7500 1500000
338250 6765000
83490 834900
10920 6552000
194573390

Subang, Oktober 2016

Kepala Puskesmas

dr.Hj. Indiati Oetama

Nip.19720929 200604 2 015
 USULAN PENGAJUAN OBAT
DANA KAPITASI JAMINAN KESEHATAN NASIONAL (JKN)
OBAT KATAGORI E KATALOG
PUSKESMAS PAGADEN TAHUN 2017

NO NAMA OBAT SATUAN KEBUTUHAN HARGA

1 Alupurinol 100mg tab 6,000 90
2 Amitriptilin 25mg tab 2,400 135
3 Amlodipin 10mg tab 3,600 396
4 Amoxicilin 500mg tab 72,000 232
5 Amoxicilin syr btl 2,400 2,090
6 Amoxicilin forte syr btl 2,400 4,854
7 Antacida doen tab 60,000 62
8 Antacida syr btl 3,600 2,520
9 Asam acetil salisilat tab 2,400 130
10 Asam mefenamat 500mg tab 36,000 106
11 Aciklovir 200mg tab 3,600 249
12 Aciklovir 400mg tab 3,600 349
13 Atropin sulfat inj amp 34 1,672
14 Aqua pro inj flc 150 2,000
15 Betahistin tab 6,000 149
16 Bedak salisil zak 600 1,025
17 Betametason krim tube 1,200 1,380
18 Dulcolak supp 10mg supp 50 5,800
19 Dulcolak supp 5mg supp 50 5,670
20 Dexametason 0,5mg tab 72,000 44
21 Diazepam 5mg tab 500 117
22 Diazepam 2mg tab 6,000 45
23 Digoxin 0,25mg tab 200 105
24 Domperidon syr btl 360 3,000
25 Domperidon 10mg tab 6,000 118
26 Dexametason inj amp 300 1,896
27 Eugenol btl 10 18,100
28 Furosemid 40mg tab 300 78
29 Garam oralit zak 6,000 264
30 Glimepirid 2mg tab 6,000 289
31 Glukosa 5% labu 1,200 6,900
32 Glibenclamid 5mg tab 12,000 67
33 Hidrocortison 2,5% tube 1,200 2,650
34 Ibupropen 400mg tab 36,000 127
35 Isosorbid dinitrat 5mg tab 500 88
36 Kalsium lactat 500mg tab 12,000 63
37 Kaptropil 25mg tab 12,000 68
38 Kaptropil 12,5mg tab 6,000 75
39 Ketokonazol krim tube 600 2,545
40 Ketorolac inj amp 1,200 1,290
41 Kloramfenicol salep mata tube 600 1,798
42 Klindamicin 300mg kapsul 6,000 664
43 Klorfeniramini maleat 4mg tab 120,000 42
44 Kodein 10mg tab 100 550
45 Kotrimoxazol syr btl 1,200 2,140
46 Kotrimoxazol 960mg tab 12,000 308
47 Lansoprazol 30mg kapsul 6,000 319
48 Lidocain+efinefrin inj amp 600 1,845
49 Lidocain inj amp 2,400 860
50 Loperamid 2mg tab 6,000 85
51 Loratadin 10mg tab 12,000 134
52 Metformin 500mg tab 12,000 100
53 Metilergometrin inj amp 600 2,684
54 Metil prednisolon 8mg tab 18,000 309
55 Metronidazol 500mg tab 12,000 133
56 miconazol salep tube 1,200 3,250
57 NaCl infus labu 1,200 6,410
58 Natrium diklofenak 50mg tab 24,000 159
59 Nipedipin 10mg tab 2,400 104
60 Ondansetron inj amp 1,200 2,880
61 Omeprazol kapsul 12,000 160
62 Ondansetron 8mg tab 6,000 299
63 Paracetamol drop btl 600 5,200
64 Paracetamol syr btl 4,200 1,074
65 Paracetamol 500mg tab 180,000 89
66 Piridoxin tab 36,000 45
67 Prednison 5mg tab 12,000 96
68 Propanolol 10mg tab 500 60
69 Popidon 1000ml btl 65 44,532
70 Ranitidin inj amp 360 1,390
71 Ranitidin 150mg tab 60,000 105
72 Ringer lactat labu 8,400 7,150
73 Salbutamol 4mg tab 2,000 83
74 Sefixim syr btl 2,399 7,490
75 Sefadroxil 125mg syr btl 1,800 4,485
76 Sefadroxil 250mg syr btl 1,800 5,585
77 Sefadroxil 500mg kapsul 15,000 510
78 Sefixim 100mg tab 12,000 590
79 Seterizin syr btl 100 2,850
80 Simvastatin 20mg tab 600 252
81 Siprofloxacin 500mg tab 24,000 281
82 Sukralfat susp btl 50 9,578
83 Thiamin 50mg tab 60,000 86
84 Vit B complek tab 60,000 43
85 Zinc 20mg tab 6,000 514
86 Genoint salep mata tube 120 2,830
87 New antides tab 12,000 228
88 Oksitosin inj amp 200 1,900
89 Ventolin nebu amp 60 4,000
90 Etanol 70% 100ml btl 200 3,000
91 Ketopropen supp supp 120 3,266
92 Metilergometrin 0,125mg tab 500 185
93 Seterizin 10mg tab 24,000 217
94 Ketokonazol 200mg tab 3,600 360
95 Epinefrin inj dus/30 1 9,720
96 Fluoxetin20mg tab 500 492
97 Zinc syr btl 100 8,880
JUMLAH TOTAL

Subang, Januari 2016

Kepala Puskesmas Pagaden Pengelola Obat Puskesmas

dr. Anggreiny Ginting Aan Kusmayanti.S.Si.,Apt

NIP. 19690914 200212 2 003 NIP.197004161992032006
SIONAL (JKN)

017

JUMLAH
Rp 540,000
Rp 324,000
Rp 1,425,600
Rp 16,704,000
Rp 5,016,000
Rp 11,649,600
Rp 3,720,000
Rp 9,072,000
Rp 312,000
Rp 3,816,000
Rp 896,400
Rp 1,256,400
Rp 56,848
Rp 300,000
Rp 894,000
Rp 615,000
Rp 1,656,000
Rp 290,000
Rp 283,500
Rp 3,168,000
Rp 58,500
Rp 270,000
Rp 21,000
Rp 1,080,000
Rp 708,000
Rp 568,800
Rp 181,000
Rp 23,400
Rp 1,584,000
Rp 1,734,000
Rp 8,280,000
Rp 804,000
Rp 3,180,000
Rp 4,572,000
Rp 44,000
Rp 756,000
Rp 816,000
Rp 450,000
Rp 1,527,000
Rp 1,548,000
Rp 1,078,800
Rp 3,984,000
Rp 5,040,000
Rp 55,000
Rp 2,568,000
Rp 3,696,000
Rp 1,914,000
Rp 1,107,000
Rp 2,064,000
Rp 510,000
Rp 1,608,000
Rp 1,200,000
 Rp 1,610,400
Rp 5,562,000
Rp 1,596,000
Rp 3,900,000
Rp 7,692,000
Rp 3,816,000
Rp 249,600
Rp 3,456,000
Rp 1,920,000
Rp 1,794,000
Rp 3,120,000
Rp 4,510,800
Rp 16,020,000
Rp 1,620,000
Rp 1,152,000
Rp 30,000
Rp 2,894,580
Rp 500,400
Rp 3,780,000
Rp 60,060,000
Rp 166,000
Rp 17,968,510
Rp 8,073,000
Rp 10,053,000
Rp 7,650,000
Rp 7,080,000
Rp 285,000
Rp 151,200
Rp 6,744,000
Rp 478,900
Rp 5,160,000
Rp 2,580,000
Rp 3,084,000
Rp 339,600
Rp 2,736,000
Rp 380,000
Rp 240,000
Rp 600,000
Rp 391,920
Rp 92,500
Rp 5,208,000
Rp 1,296,000
Rp 9,720
Rp 246,000
Rp 888,000
Rp 322,210,978

Subang, Januari 2016

Pengelola Obat Puskesmas

Aan Kusmayanti.S.Si.,Apt
NIP.197004161992032006
 USULAN PENGAJUAN ALKES
DANA KAPITASI JAMINAN KESEHATAN NASIONAL (JKN)
ALKES KATAGORI E KATALOG
PUSKESMAS PAGADEN TAHUN 2017

N0 NAMA ALKES SATUAN KEBUTUHAN

1 Dental Unit unit 1
2 Micropipet pariable 5r-100 unit 1
3 Micropipet pariable 100r-100 unit 1
4 Suction pump unit 1
5 Examination lamp unit 1
Jumlah Total

Kepala Puskesmas Pagaden

dr. Anggreiny Ginting

NIP. 19690914 200212 2 003
UAN ALKES
EHATAN NASIONAL (JKN)
E KATALOG
EN TAHUN 2017

HARGA JUMLAH
Rp 150,000,000 ###
Rp 594,000 Rp 594,000
Rp 594,000 Rp 594,000
Rp 46,200,000 Rp 46,200,000
Rp 60,000,000 Rp 60,000,000
Rp 257,388,000

Subang, Januari 2017

Pengelola Obat Puskesmas

Aan Kusmayanti.S.Si.,Apt
NIP.197004161992032006
 USULAN PENGAJUAN BAHAN MEDIS HABIS PAKAI
DANA KAPITASI JAMINAN KESEHATAN NASIONAL (JKN)
PUSKESMAS PAGADEN TAHUN 2017
NO NAMA BMHP SATUAN KEBUTUHAN HARGA
1 XRF 24x30 lmb/100 4 1,656,720
2 XRF 35x35 lmb/100 5 2,916,000
3 Developer Ref 20L galon/10L 6 1,386,000
4 Fixer 20L galon/10L 6 1,056,000
5 Widal O vial 14 205,920
6 Widal H vial 10 205,920
7 Widal AO vial 10 205,920
8 Widal AH vial 10 205,920
9 Diluent galon 2 4,309,800
10 Cleaner botol 2 4,653,000
11 Lyse botol 2 5,814,000
12 Darah kontrol vial 3 1,782,000
13 Stick urine tube 10 871,200
14 Pewarna gram kit 2 891,000
15 Eosin botol 2 240,000
16 Cuvet BS 120 box 1 9,240,000
17 Yellow TIP zak 3 330,000
18 Vacultainer box 2 174,000
19 Lancet box 10 180,000
20 Olie imersi botol 2 312,000
21 BHCG box 5 396,000
22 Anti sera A vial 21 165,000
23 Anti sera B vial 20 165,000
24 Anti sera D vial 20 260,040
25 Kartu golongan darah pack 10 120,000
26 Alat suntik 1cc set 2000 780
27 Alat suntik 3cc set 6000 780
28 Alat suntik 5cc set 2400 900
29 Infuset dewasa bh 3699 3,840
30 Kasa 16x16 box 199 6,960
31 Surgical Mask 3 ply Earlop box/30 200 19,800
32 Surgical Mask 3 ply tie on box/30 200 19,800
33 Kasa pembalut 4x15 rol 201 2,100
34 Infuset anak bh 1200 12,487
35 Bioplasenton tulle box/100 19 39,000
36 Silk box/36 21 110,000
37 Sarung tangan box/100 61 47,600
JUMLAH TOTAL

Subang, Januari 2017

Kepala Puskesmas Pagaden Pengelola Obat Puskesmas

dr. Anggreiny Ginting Aan Kusmayanti.S.Si.,Apt

NIP. 19690914 200212 2 003 NIP.197004161992032006
IS HABIS PAKAI
N NASIONAL (JKN)
UN 2017
JUMLAH
Rp 6,626,880
Rp 14,580,000
Rp 8,316,000
Rp 6,336,000
Rp 2,882,880
Rp 2,059,200
###
Rp 2,059,200
Rp 8,619,600
Rp 9,306,000
Rp 11,628,000
Rp 5,346,000
Rp 8,712,000
Rp 1,782,000
Rp 480,000
Rp 9,240,000
Rp 990,000
Rp 348,000
Rp 1,800,000
Rp 624,000
Rp 1,980,000
Rp 3,465,000
Rp 3,300,000
Rp 5,200,800
Rp 1,200,000
Rp 1,560,000
Rp 4,680,000
Rp 2,160,000
Rp 14,204,160
Rp 1,385,040
Rp 3,960,000
### `
Rp 422,100
Rp 14,984,400
Rp 741,000
Rp 2,310,000
Rp 2,903,600
Rp 172,211,060

ubang, Januari 2017

Pengelola Obat Puskesmas

Aan Kusmayanti.S.Si.,Apt
NIP.197004161992032006