PENGADAAN OBAT BPJS SESUAI FORMULARIUM NASIONAL

Jumlah Data
No. Nama/Jenis Barang Spesifikasi Anggaran Harga
(unit) Pendukung
1 ACARBOSE 50 MG TAB 100 OGB 140,000.00 1400
4 Acyclovir 400 mg 1200 OGB 840,000.00 700
5 ACYCLOVIR CREAM 5 GRAM 50 OGB 185,000.00 3700
9 ALLOPURINOL 100 MG TAB 600 OGB 150,000.00 250
11 AMINOPHYLLIN TAB 200 MG 100 OGB 20,000.00 200
12 Aminophyllinum amp 24 mg/ml x 48 OGB 278,400.00 5800
13 AMITRIPTILIN 25 MG TABLET 2000 OGB 300,000.00 150
14 AMLODIPINE TAB 5 MG 1080 OGB 1,296,000.00 1200
15 AMOXICILLIN 500 MG TAB 1200 OGB 540,000.00 450
18 Antalgin 500 mg tab 500 OGB 100,000.00 200
19 Antasida tab 600 OGB 90,000.00 150
21 Antropini Sulfas 0.25 MG/Ml INJ 100 OGB 160,000.00 1600
22 Asam mefenamat 500 mg 1000 OGB 170,000.00 170
23 ASAM TRANEKSAMAT 500 MG TA 900 OGB 1,080,000.00 1200
39 Bricasma amp 0.5 mg/mL 660 Aztra Zeneca 14,256,000.00 21600
40 Bricasma tab 2.5 mg 100 Aztra Zeneca 260,000.00 2600
44 CAIRAN AMINOFLUID L 500 ML 2 Otsuka 230,000.00 115000
45 Cairan Asering 500 ml 100 Otsuka 1,580,000.00 15800
46 Cairan D10 1/5 NS 500 ml 100 Otsuka 1,350,000.00 13500
47 CAIRAN NACL 0,9% 500 ML OGB 200 Widatra 1,100,000.00 5500
48 Cairan Otsu D 5 % 1/4 NS 1060 Otsuka 13,250,000.00 12500
49 Cairan Otsu D10 % 500 ml 240 Otsuka 3,240,000.00 13500
50 Cairan Otsu D5 1/2 Ns 500 mL 600 Otsuka 7,200,000.00 12000
51 Cairan Otsu D5 500ml 280 Otsuka 2,940,000.00 10500
52 Cairan Otsu Ns 500 ml 200 Otsuka 2,100,000.00 10500
53 Cairan otsu Rinjer Lactat 500 ml 2800 Otsuka 31,920,000.00 11400
54 Cairan Ringer Dextrose 5 % 500 240 Otsuka 3,000,000.00 12500
55 CAIRAN RL WIDATRA GENERIK 5 100 Widatra 600,000.00 6000
56 CAIRAN WIDA RL 1000 ML 20 Widatra 260,000.00 13000
57 CALCU GLUCONAS 10 % 48 OGB 576,000.00 12000
59 Captopril 25 mg tab 200 OGB 40,000.00 200
61 Caviplek tab 3600 Erella 1,620,000.00 450
62 CEFADROXIL 500 MG KAPSUL 7500 OGB 9,000,000.00 1200
63 CEFADROXIL SYRUP 125MG/5ML 450 OGB 5,175,000.00 11500
64 CEFILA (CEFIXIM 100 MG) KAPSU 1800 OGB 31,860,000.00 17700
65 Cefixim cap 100 mg 1800 OGB 5,940,000.00 3300
66 Cefixime Dry Syrup 200 OGB 8,360,000.00 41800
67 CEFOTAXIM 1G INJ 1500 OGB 14,400,000.00 9600
68 CEFTRIAXON INJ 1G 250 OGB 2,950,000.00 11800
69 Cendo Xitrol 5 mL 60 Cendo 2,070,000.00 34500
70 CETIRIZIN SYR 5MG/5ML 40 OGB 480,000.00 12000
 71 Chlorpromazine 25 mg tab 0 OGB 0.00 150
72 CHROMALUX (MISOPROSTOL 200 400 Pharos 4,320,000.00 10800
73 Cinam 1 gr Inj I.m/ I.v 1000 Sanbe 155,500,000.00 155500
74 CINOLON CREAM 30 Sanbe 537,000.00 17900
75 Ciprofloxacin 500 mg Novel 10200 OGB 4,590,000.00 450
76 Cleanser N / Dry (C1) 240 CDE 4,320,000.00 18000
77 Cleanser Oily / Acne (C3) 500 CDE 8,000,000.00 16000
78 CLINDAMYCIN 300 MG KAPSUL 1200 OGB 2,520,000.00 2100
79 CLINIDAC (KLINDAMISIN) 300 MG 900 Pharos 5,940,000.00 6600
80 Cobazim caps 100 Interbat 280,000.00 2800
81 CODEIN 20 MG TAB 1000 KF 1,250,000.00 1250
82 Colfin syrup 60 ml 0 Nufarindo 0.00 7500
83 Colistine 1500000 IU TB 50 Actavis 325,000.00 6500
84 COLME EAR DROP 5 Interbat 120,000.00 24000
85 Colme eye drops 8 ml 60 Interbat 1,440,000.00 24000
86 Colsancetin inj 250 Sanbe 2,875,000.00 11500
87 COROSORB (ATTAPULGITE 600 MG 500 Coronet 100,000.00 200
88 Cotrimoxazol tab 480 mg 1800 OGB 450,000.00 250
89 CREAM ANTI IRITASI (Ai) 25 CDE 400,000.00 16000
90 Cream mata anti wringkle (AW) 15 CDE 375,000.00 25000
91 Cream Mata Dark Circle (DC) 15 CDE 525,000.00 35000
92 Cream Mata Eye Bag (EB) 10 CDE 200,000.00 20000
93 CTM 4mg tab 3224 PIM 161,200.00 50
94 Cupanol Syrup 60 ml 600 Guardian 12,600,000.00 21000
95 Daily Cream Acne (SB3) 150 CDE 3,225,000.00 21500
96 Daily Cream Normal (SB1) 250 CDE 4,375,000.00 17500
97 Daily Cream Oily (SB2) 750 CDE 13,125,000.00 17500
98 Daily White Cream (W1) 250 CDE 8,175,000.00 32700
99 Dextamine tab 7500 Phapros 12,165,000.00 1622
100 Dextral Forte Capsul 500 mg 1200 Molex Ayus 660,000.00 550
101 Dextral tab 500 mg 3750 Molex Ayus 1,500,000.00 400
102 Dextrose Injection 40% 20 Otsuka 42,000.00 2100
103 Dimenhidrinate tab 200 OGB 40,000.00 200
104 DOM SUSPENSI 60 ML (DOMPER 300 Lapi 11,400,000.00 38000
105 Dopamet 250 mg 100 Actavis 250,000.00 2500
106 DORMI COMP TAB 100 Zenith 180,000.00 1800
107 DRAMAMIN (DIMENHIDRINAT 50 300 Soho 480,000.00 1600
108 Dulcolax Supp Adult 10 mg 240 Boeringer Ing. 3,600,000.00 15000
109 Dulcolax supp anak 5 mg 5 Boeringer Ing. 72,500.00 14500
110 Dulcolax tab 5 mg 200 Boeringer Ing. 2,200,000.00 11000
111 Dumin Rectal 125 Mg / 2.5 ml 60 Actavis 810,000.00 13500
112 Duphaston 10 mg 2200 Abbot 36,740,000.00 16700
113 Elkana Film-coated tab 18600 Sanbe 14,880,000.00 800
114 ELOX CREAM 5 GRAM (MOMETAS 36 Guardian 1,440,000.00 40000
115 Emibion Kapsul 3600 Guardian 4,680,000.00 1300
116 Eminetton tab 10000 Kalbe 17,000,000.00 1700
117 EPHEDRINE HCL INJ 240 OGB 15,120,000.00 63000
118 Epineprin Inj 100 OGB 290,000.00 2900
119 Ericaf 30 Tempo 174,000.00 5800
120 Erlamycetin Chloramphenicol Sal 25 Erella 140,000.00 5600
121 Erlamycetin ear drop 10 mL 30 Erella 165,000.00 5500
122 ERYTHRIN (ERYTHROMYCIN) DRY 40 Interbat 1,320,000.00 33000
123 Erythromycin 500 mg Generik 500 OGB 600,000.00 1200
124 ERYTHROMYCIN SYRUP 60 ML 50 OGB 575,000.00 11500
125 ERYTROMYCYN 250 MG 300 OGB 180,000.00 600
126 Estesia 30gr cream 0 Itech Lafacos 0.00 216500
127 ETHIGENT INJ 80MG AMP 2ML ( 60 Ethica 780,000.00 13000
128 Exaflam 50 mg tab 4200 Guardian 10,920,000.00 2600
129 Extrace 500 mg ampul 240 Ethica 6,072,000.00 25300
130 Extropect syrup 60 ml 240 Guardian 6,360,000.00 26500
131 EXTROPECT TAB (AMBROXOL 30 7200 Guardian 7,920,000.00 1100
132 Facial Wash (FW) Normal / Dry (F 15 CDE 277,500.00 18500
133 Farbion inj 200 Fahrenheit 1,200,000.00 6000
134 FARMABES (DILTIAZEM HCL 30 MG 2 Fahrenheit 253,000.00 126500
135 Farsix Amp 10 mg / mL 120 Fahrenheit 1,020,000.00 8500
136 Fasorbid 5 mg 200 Fahrenheit 60,000.00 300
137 FENTANYL 0.05 MG/ML AMPUL 2 120 OGB 5,940,000.00 49500
138 Ferofort film coated caplet 10000 Kalbe 18,000,000.00 1800
139 FEROSPAT TABLET EFFERVESCENT 240 Pyridam 12,240,000.00 51000
140 Fetik supp 600 Interbat 7,200,000.00 12000
141 Flagyl supp 0.5 g 10 Sanofi 125,000.00 12500
142 Flagyl supp 1 g 200 Sanofi 5,160,000.00 25800
143 Flagyl syrup 60 mL 80 Sanofi 4,520,000.00 56500
144 FLIXOTIDE NEBULE O.5 MG 60 GSK 1,320,000.00 22000
145 Folamil caplet 4800 Dexa Medica 5,760,000.00 1200
146 Folamil Genio botle @ 30 soft ca 800 Dexa Medica 94,160,000.00 117700
147 FW Acne (FA1) 400 CDE 9,200,000.00 23000
148 FW Acne 2 (FA2) 250 CDE 9,000,000.00 36000
149 FW Kulit Sensitif (F2) 30 CDE 828,000.00 27600
150 FW Oily (FO) 10 CDE 200,000.00 20000
151 FW SCRUB COKLAT (FWSC) 0 CDE 0.00 25500
152 FW SCRUB NATURAL (FWSP) 0 CDE 0.00 25500
153 FW Whitening (F1) 200 CDE 4,700,000.00 23500
154 GALFLUX TAB 1200 Guardian 5,400,000.00 4500
155 GASTRIDIN (RANITIDIN) 2 ML A 200 Interbat 4,400,000.00 22000
156 Gastrucid Syr 60 mL 60 Nufarindo 360,000.00 6000
157 Gastrul 720 Fahrenheit 4,680,000.00 6500
158 Gelafusal 500 ml 60 Dexa Medica 12,540,000.00 209000
159 GENOINT (GENTAMYCIN) SALEP K 70 Erella 315,000.00 4500
160 GENTAMYCIN TETES MATA 0,3% 40 Cendo 1,440,000.00 36000
161 GENTAMYCINE 0.3% SALEP MATA 35 Cendo 1,610,000.00 46000
162 Gentian Violet 15 Onemed 22,500.00 1500
163 Gerovital 0 0.00 50600
164 GETIDIN (RANITIDIN 25MG/ML) 450 Guardian 9,675,000.00 21500
165 GLIBENCLAMIDE TAB 5 MG 0 OGB 0.00 150
166 Glimepiride 2 mg tab 800 OGB 1,360,000.00 1700
167 Heptasan tab 100 Sanbe 30,000.00 300
168 HUMULIN R 100 IU/10 ML 2 Lily;Tempo 734,000.00 367000
169 HYDROCORTISON KRIM 2.5% 10 OGB 45,000.00 4500
170 Hystolan tab 1200 Dexa Medica 6,600,000.00 5500
171 Imunos syrup 60 mL 250 Lapi 16,625,000.00 66500
172 Imunos tab 480 Lapi 3,360,000.00 7000
173 Indexon tablet 5000 Interbat 2,000,000.00 400
174 INDOP (DOPAMIN) INJ 40MG/ML 3 Fahrenheit 114,000.00 38000
175 Induxin amp 1800 Kalbe 18,900,000.00 10500
176 INERSON (DEXOSIMETHASONE 0, 30 Interbat 975,000.00 32500
177 INOTROP (DOBUTAMIN) VIAL 3 Fahrenheit 376,500.00 125500
178 INTERLAC OIL DROP 15 Interbat 2,820,000.00 188000
179 Intermoxil Forte Syr 60 ml 100 Interbat 3,450,000.00 34500
180 Intermoxil 500 mg 3000 Interbat 10,500,000.00 3500
181 Intermoxil Syr 60 ml 600 Interbat 14,400,000.00 24000
182 Interzol cream 5 gr 60 Interbat 1,404,000.00 23400
183 Intrizin Drop 15 ml 150 Interbat 10,275,000.00 68500
184 INVICLOT (HEPARIN) INJ. VIAL 3 Fahrenheit 228,000.00 76000
185 Iodine Povidone btl 60 ml 480 Onemed 3,072,000.00 6400
186 Iremax tab 2000 Guardian 2,000,000.00 1000
187 Ironyl kaplet 4800 Guardian 12,000,000.00 2500
188 KA EN 3B INFUS 500 ML 240 Otsuka 4,320,000.00 18000
189 Kaditic 50 900 Ifars 315,000.00 350
190 Kalmethason 4mg amp 1500 Kalbe 11,400,000.00 7600
191 KB Andalan Inj 3 bulan 120 Andalan 948,000.00 7900
192 KB Andalan Inj 1 bulan 60 Andalan 540,000.00 9000
193 K-Ceutic (KC) 10 Itech Lafacos 5,313,000.00 531300
194 KCL 1 mEq25 CC 15 Otsuka 42,000.00 2800
195 Kenalog In - Orabase 5 gr 70 Taisho 3,955,000.00 56500
196 Ketokonazole 200mg tab 500 OGB 250,000.00 500
197 Ketorolax inj 600 OGB 9,300,000.00 15500
198 Ketros supp 300 Pharos 3,600,000.00 12000
199 KTM 100 mg /ml Inj 36 Guardian 8,013,600.00 222600
200 Lactacid baby 60 ml 50 PPG 1,150,000.00 23000
201 Lacto B sachet/Jovial+zinc 960 Novell/Galenium 4,608,000.00 4800
202 LACTOPAIN (KETOROLAC TROME 600 Lapi 21,600,000.00 36000
203 Laktafit tab 600 Dexa Medica 1,860,000.00 3100
204 Lapiflox 500mg tab 360 Lapi 5,040,000.00 14000
205 Lasal 4 mg tab 3600 Lapi 6,120,000.00 1700
206 Laxoberon drop 10 ml 5 Boeringer Ing. 350,000.00 70000
207 L-Bio sachet 3600 Lapi 23,400,000.00 6500
208 levofloxacin 30 OGB 51,000.00 1700
209 Lidocaine 2 % amp 1000 OGB 1,500,000.00 1500
210 LIDODEX 0 Bernofarm 0.00 63500
211 Likurmin syr 100 ml 250 Kalbe 9,500,000.00 38000
212 Lokev kapsul 300 Ifars 210,000.00 700
213 Loose Powder Acne (B2) 80 CDE 2,160,000.00 27000
214 Loose Powder Hi Grade (B1) 75 CDE 3,750,000.00 50000
215 LORATADIN 10 MG NOVEL 900 OGB 360,000.00 400
216 Lynoral tab 600 Organon 1,200,000.00 2000
217 Maganol tab 3600 Guardian 1,800,000.00 500
218 Maghtral syr 120 ml 400 Otto 10,200,000.00 25500
219 Mecobalamin 500 mcg tab 500 OGB 442,500.00 885
220 MEDIAMER B6 TAB 3000 Darya Varia 10,500,000.00 3500
221 Mefinal cap 250 mg 4000 Sanbe 2,800,000.00 700
222 Mefinal Film-coated caplet 500 1500 Sanbe 2,250,000.00 1500
223 Mefinter 500 mg 1800 Interbat 2,880,000.00 1600
224 Meixam 500mg caps 100 Meiji 450,000.00 4500
225 MELOXICAM 7,5 MG TABLET 200 OGB 200,000.00 1000
226 Merosan Inj 0.5 gr 130 Sanbe 39,065,000.00 300500
227 Mertigo tab 200 Dexa Medica 700,000.00 3500
228 METFORMIN 500 MG TAB 600 OGB 150,000.00 250
229 Methisoprinol syr 15 OGB Landson 952,500.00 63500
230 METHYLPREDNISOLONE 125 mg vi 60 OGB 3,036,000.00 50600
231 METHYLPREDNISOLONE 4MG TAB 2500 OGB 1,250,000.00 500
232 Metronidazol infus 5.0 mg / mL 10 OGB 580,000.00 58000
233 Meylon 84 10 Otsuka 216,000.00 21600
234 Mezatrin 250 mg 30 Sanbe 465,000.00 15500
235 Microlax Supp 120 Novell 2,220,000.00 18500
236 Mikasin inj 250 mg 150 Kalbe 13,800,000.00 92000
237 Milmor tab 10800 Pharos 32,400,000.00 3000
238 MILOZ (MIDAZOLAM) INJ 5mg 120 Novell 3,060,000.00 25500
239 Minosep gargle 0.2 - 150ml 5 PPG 132,500.00 26500
240 Moisturizer N / Dry (MC) 25 CDE 525,000.00 21000
241 Moloco tab 2400 Darya Varia 0.00 2770.2
242 MORFIN INJ 700 KF 0.00 9611
243 MUCOS (AMBROXOL 30MG) TABL 5000 Meprofarm 0.00 800
244 Murec caps/ Imuno caps 8000 dr. Rudi 0.00 7000
245 Natrium Diklofenak 50 mg 1500 OGB 0.00 197.9
246 NC1 KM SEMPURNA 25 Kitoderm 0.00 34000
247 NC2 (2W) KMS 20 KMS 0.00 35000
248 Neo Kaominal Syr 60 ml 120 Molex Ayus 0.00 5750
249 Neo-K 2 mg / ml inj 540 Combiphar 0.00 12320
250 Neosinol cream 60 Interbat 0.00 16925
251 Neurobat A tab 200 Interbat 0.00 970
252 Neurodex tab 1800 Dexa Medica 0.00 395
253 NEUROTROPIC INJEKSI 9 ML 10 Aditama 0.00 7272.7
254 New Diatabs tab 600 mg 600 Medifarma 0.00 440
255 Nifedipine tab 7000 OGB 0.00 117.3
256 NIGHT CREAM LIGHTENING WHIT 100 CDE 0.00 21500
257 NIGHT CREAM SUPER WHITE (NC 140 CDE 0.00 22000
258 Night Cream Super White 5 (NC3) 500 CDE 0.00 22500
259 Norelut tab 5 mg 4200 Dexa Medica 0.00 3750
260 Novalgin Inj 50 Sanofi 0.00 8621.6
261 NUCEF (CEFIXIM 100MG/5ML) SY 0 Guardian 0.00 68000
262 NUCRAL (SUCRALFATE 1000 MG/ 450 Guardian 0.00 4750
263 NUTRIBABY ROYAL PRONUTRA 1 5 Nutricia 0.00 109874.5
264 Nutriflam tab 2880 Tropica Mas 0.00 7950
265 Nyndia Drop 12 ml 20 Guardian 0.00 30000
266 Obipluz 30's Cap 6000 Darya Varia 0.00 2437.3
267 ODR 8 MG 200 Lapi 0.00 35000
268 Omeprazole 20 mg caps 1200 OGB 0.00 371.2
269 ONDANE INJ 2 ML (ONDANSENTR 960 Guardian 0.00 24500
270 ONDANE INJ 4 ML (ONDANSETRO 120 Guardian 0.00 37000
271 ONDANSETRON 4 MG AMPUL 15 OGB 0.00 7000
272 ONDANSETRON 4 MG TAB 480 OGB 0.00 1432.2
273 Ondansetron syr 10 OGB 0.00 40000
274 Opilax syr 40 Otto 0.00 33000
275 OPOX (LOPERAMID) TAB 780 Guardian 0.00 1000
276 OSSORAL200 TABLET 20000 Dexa Medica 0.00 1000
277 Osteocare Syrup 100 mL 25 Vitabiotic 0.00 40000
278 Otsu - WI 25 mL 3600 Otsuka 0.00 2900
279 OTSU D5-PIGGYBACK 100 ML 15 Otsuka 0.00 9100
280 OTSU MAGNESITUS SULFAT 20% 20 Otsuka 0.00 3600
281 OTSU MAGNESITUS SULFAT 40% 140 Otsuka 0.00 4800
282 Otsu Ns 25 ml 240 Otsuka 0.00 4800.4
283 OTSU NS-PIGGYBACK 100 ML 100 Otsuka 0.00 3400
284 Otsu WI 1000 ml 36 Otsuka 0.00 10100
285 Ozen drops 250 Pharos 0.00 60000
286 Ozen Syrup 60 ml (pharos) 120 Pharos 0.00 50000
287 Ozen tab 10 Mg 60 Pharos 0.00 4333.3
288 PAMOL 250 MG SUPP 144 Interbat 0.00 9400
289 Pamol oral drop 15 ml 360 Interbat 0.00 19950
290 Pamol sup 125 mg 864 Interbat 0.00 6850
291 Pan Amin G Inj 500 ML 80 Otsuka 0.00 45000
292 PANTOCAIN TETES MATA 2% 1 Cendo 0.00 13250
293 PANTOPUMP 12 Interbat 0.00 105000
294 Paracetamol tab 500 mg 2500 OGB 0.00 113.6
295 Pectocil 200 mg 1800 Ethica 0.00 2450
296 Pedialyte 120 Abbot 0.00 20000
297 Pehacain inj 2 mL 120 Phapros 0.00 2830.1
298 PETHIDINE HCL 50 MG AMPUL 2 400 KF 0.00 12283
299 PHAROLIT RASA JERUK 600 Novell 0.00 840
300 PHENOBARBITAL (LUMINAL) 30 M 4500 KF 0.00 63.7
301 Piralen amp 5 mg/mL x 2 mL 200 Otto 0.00 5500
302 Piralen Syrup/ Vomitrol syr 40 Otto/Pharos 0.00 7500
303 Piralen tab 10 mg 2000 Otto 0.00 450
304 PITOGIN S (OXYTOCIN S) INJ AMP 20 Ethica 0.00 4810
305 Pospargin amp 1000 Kalbe 0.00 5500
306 Pospargin methylergometrine ma 5000 Kalbe 0.00 500
307 Praxion Drop 100 mg / mL 15 mL 180 Pharos 0.00 18000
308 Pregvomit tab 4800 Fahrenheit 0.00 2000
309 Proanes ampul 20 Sanbe 0.00 66195
310 Profen syr 200 Guardian 0.00 16000
311 Progastric 600 Combiphar 0.00 275
312 Promavit caps 3600 Lapi 0.00 1600
313 PRORIS (IBUPROFEN 200 MG) TA 1000 Pharos 0.00 880
314 Prostigmin ampul 15 Combiphar 0.00 14444.6
315 Provula tab 50 mg 720 Dexa Medica 0.00 11300
316 Pycin 750 mg vial 80 Bernofarm 0.00 75000
317 Ranitidin tab 150 mg 3000 OGB 0.00 240
318 Ranitidin Inj 60 OGB 0.00 3150
319 Rhinofed tab 5000 Dexa Medica 0.00 1540
320 Rodo 675 amp 20 Rodotech 0.00 20000
321 RYDIAN (CETIRIZINE) TAB 1440 Guardian 0.00 3350
322 Safol ampul 40 Novell 0.00 85000
323 SALBUTAMOL 2 MG 3600 OGB 0.00 76.3
324 SALBUTAMOL 4MG TAB 1200 OGB 0.00 102.3
325 Sanbe Kids syr. 200 ml 70 Sanbe 0.00 30500
326 Sanmol 500 tab 6000 Sanbe 0.00 240
327 SANTA E 200 TABLET 14500 Sanbe 0.00 1660
328 Santa E 400 mg 3600 Sanbe 0.00 3260
329 Santa-E Sugar-coated caplet 100 36000 Sanbe 0.00 725
330 SB3 10 KMS; Kito 0.00 14000
331 SB4 + TTO CREAM 10 Kitoderm 0.00 25000
332 SB5 + H1 30 Kitoderm 0.00 20500
333 SCOPAMIN (HYOCINE BUTILBROM 300 Otto 0.00 1100
334 SERUM PENGECIL PORI (D5) 25 CDE 0.00 20900
335 SIDIADRYL INJ 5 Bernofarm 0.00 10000
336 Simvastatin 10 mg 2400 OGB 0.00 559.6
337 SIMVASTATIN 20 MG TAB 300 OGB 0.00 932.7
338 Sinobiotik cream 300 Galenium 0.00 12000
339 Sirplus rasa jeruk 60 Meprofarm 0.00 10500
340 SIRPLUS SIRUP RASA STROBERI 1 60 Meprofarm 0.00 10500
341 Sistenol tab 420 Dexa Medica 0.00 1400
342 SM1 10 Kitoderm 0.00 14500
343 SM2 10 Kitoderm 0.00 14800
344 SM3 60 Kitoderm 0.00 17000
345 Smecta 60 IPSEN; APL 0.00 2666.7
346 SOLVINEX (BROMHEXIN 8 MG) TA 1500 Meprofarm 0.00 400
347 Spasminal tab 600 Hexpharm 0.00 470
348 Spiramycin 1,5 M IU Novell 1000 OGB 0.00 1400.9
349 Sporetik 100 mg capsule 360 Sanbe 0.00 17000
350 Stesolid 2mg tab 2400 Actavis 0.00 800
351 Stesolid amp 10 mg/2 mL (Injecsi 120 Actavis 0.00 10400
352 Stesolid rectal 5 mg / 2.5 mL 120 Actavis 0.00 21600
353 Starxon 1g (Ceftriaxon) vial 600 Interbat 0.00 172500
354 SUNBLOCK NORMAL WHITE SPF50 50 CDE 0.00 17272.7
355 Supralysin drop 600 Meprofarm 0.00 20000
356 Susu LLM 50 SGM 0.00 27932
357 Susu Formula 1 Nutrilon dos 200 60 Nutricia 0.00 43200
358 Susu Nutrilon AR 400 gr 3 Nutricia 0.00 95391.8
359 Susu Nutrilon HA 400 gram 15 Nutricia 0.00 122533.6
360 Susu Nutrilon Soya 1 400 gram d 50 Nutricia 0.00 77584.5
361 Susu Nutrilon Soya 2 400 gram d 0 Nutricia 0.00 77584.5
362 Susu SGM 1 dos 120 gr 60 SGM 0.00 9000
363 Susu SGM BBLR dos 200 g 36 SGM 0.00 31091
364 Tantum verde oral rinse 120ml 0 PPG 0.00 30000
365 Tathionil Roche 20 Roche 0.00 62500
366 Taxegram Inj 1 g im/iv 180 Sanbe 0.00 122975
367 Terrell 100 ml/0 1 Fahrenheit 0.00 480000
368 Thiamphenicol 500 mg caps 600 OGB 0.00 560
369 Thiamycin 500 mg cap 7200 Interbat 0.00 3300
370 Thiamycin syr 60 ml 200 Interbat 0.00 25000
371 Thiamycin syr forte 60 ml 50 Interbat 0.00 45000
372 Thrombophob gel 15 Tunggal Idaman 0.00 45000
373 Toner Acne (T2) 550 CDE 0.00 17050
374 Toner Normal / Dry (T1) 200 CDE 0.00 13200
375 Toner Oily (T3) 60 CDE 0.00 15620
376 TOPAZOL (PANTOPRAZOLE) VIAL 180 Lapi 0.00 115000
377 Tramadol inj 600 OGB 0.00 5820
378 Tramadol tab 500 mg 0 OGB 0.00 321
379 Tranabat syr 50 Triyasa 0.00 6500
380 Tranabat tab 500 Triyasa 0.00 270
381 TRANSAMIN (ASAM TRANEKSAMA 100 Otto; ITC 0.00 2500
382 Transamin amp 5 % 50 Otto; ITC 0.00 10500
383 Trifed Tab 6000 Interbat 0.00 1250
384 TRIMOXSUL (COTRIMOXSAZOL) 4 1000 Interbat 0.00 750
385 TRIMOXSUL FORTE TAB (COTRIM 400 Interbat 0.00 1550
386 Trimoxul syrp 50 ml 250 Interbat 0.00 20850
387 Triomin E caps 19500 Zenith 0.00 1350
388 Ursodeoxycholic acid tab 90 OGB 0.00 4200
389 UTROGESTAN 100MG CAPS 6000 Lapi 0.00 7500
390 Vaksin ACTHIB (Hib) 5 Sanofi 0.00 181500
391 Vaksin Avaxim 80 (Hep A) 12 Sanofi 0.00 242000
392 Vaksin BCG 20 Biofarma 0.00 5000
393 Vaksin Campak 20 Biofarma 0.00 5000
394 Vaksin DPT 20 Biofarma 0.00 5000
395 Vaksin Euvax B (Hep B) 40 Sanofi 0.00 46000
396 Vaksin Hepatitis B 120 Biofarma 0.00 5000
397 Vaksin Hyperhep 25 Dipa Pharmalab 0.00 1980000
398 Vaksin Hyperho 1 Dipa Pharmalab 0.00 2200000
399 Vaksin Imovax Polio 10 Sanofi 0.00 82500
400 Vaksin Infarix-IPV+HIB 8 GSK 0.00 315000
401 Vaksin Pediacel (DTP, Polio, HIB) 4 Sanofi 0.00 391125
402 Vaksin Pentabio 25 Biofarma 0.00 5000
403 Vaksin Polio 60 Biofarma 0.00 5000
404 Vaksin Rotarix 3 GSK 0.00 205000
405 Vaksin Synflorix (Pneumoni) 3 GSK 0.00 395000
406 Vaksin Trimovax (MMR) 5 Sanofi 0.00 91875
407 Vaksin Tripacel (DPTa) 15 Sanofi 0.00 228800
408 Vaksin TT 5 Biofarma 0.00 5000
409 Vaksin Typhim VI 0,5ml 15 Sanofi 0.00 104500
410 Ventolin Nebules 960 GSK 0.00 8000
411 Viccilin 1g vial 1000 Meiji 0.00 9600
412 Vioxy.fm kaplet 28800 Fahrenheit 0.00 3500
413 Vit. B Complex tab 5000 OGB 0.00 19.1
414 Vitamin B6 tab 100 OGB 0.00 134.6
415 VITAMIN C 50 MG 5000 OGB 0.00 96
416 V-LACTO 120 Pharos 0.00 3750
417 Vometa 10 mg Tab 750 Dexa Medica 0.00 3600
418 Vometa drop 30 Dexa Medica 0.00 37500
419 Vometa syr 70 Dexa Medica 0.00 38000
420 Vomidon drop 60 Pharos 0.00 22500
421 WIDAHES 0 Widatra 0.00 156500
422 Xylomidon inj (Durafarma ) 25 Durafarma 0.00 5555
423 Yal 67.5 mL solution 0 PPG 0.00 65000
424 ZEPHANAL CAPS 9000 Zenith 0.00 3000
425 ZINC 20 MG TABLET 1200 OGB 0.00 431.4
426 Zinkid Tab 400 Indofarma 0.00 2500
427 ZIRCUM (ZINC 20MG/5ML) 60 ML 450 Meprofarm 0.00 24000
428 ZONAL (EPERISON 50 MG) TAB 100 Kalbe 0.00 2250
Total Perencanaan Pengadaan Rutin Tahun 2015 ###
Pengadaan obat baru 5% dari Total Perencanaan 0.00
Total Perencanaan Pengadaan Obat tahun 2015 ###
PENGADAAN OBAT BPJS SESUAI FORMULARIUM NASIONAL

Jumlah
No. Nama/Jenis Barang Spesifikasi
(unit)
1 Fentanyl inj. 0,05mg/ml 150 Kimia farma
2 Fentanyl patch 12,5 mcg/jam 5 Durogesic 12,5 MU matrix KF
3 Kodein 20 mg tab 1000 Kimia farma
4 Morfin inj. 10 mg/ml 150 Kimia farma
5 Pethidin inj. 50mg/ml 150 Kimia farma
6 Asam mefenamat 250 mg 2000 Datan Pyridam
7 Asam mefenamat 500 mg 4000 Bernofarm
8 Ibuprofen 200 mg tab 1000 Yarindo Fahrenheit
9 Ibuprofen 400 mg tab 1500 Novapharin
10 Ibuprofen syr 100 mg/5ml 300 Indofarma
11 Ketoprofen 100 mg 1200 Protofen KF
12 Ketorolak inj. 30 mg/ml 600 Phapros; HJ
13 Natrium diklofenak 50 mg tab 3000 Phapros; Novell
14 Parasetamol tab 500 mg 10000 Promedraharjo
15 Parasetamol syr 120 mg/5ml 2000 Afifarma
16 Parasetamol drop 60mg/0,6 ml 1000 Indofarma
17 Tramadol inj. 10 mg/ml 500 Natura; Novell;
18 Alopurinol 100 mg tab 2000 HJ
19 Bupivakain heavy spinal inj. 240 Dexa
20 Etil klorida spray 15
21 Lidokain 2% ampul 1200 Bernofarm
22 Lidocaine 2 % + Epinefrin 1:80000, amp 2 ml 240 Indofarma
23 Lidocaine jeli 2% 3 Xylocaine Astrazeneca
24 Lidocain spray 10% 3 Xylocaine Astrazeneca
25 Isofluran 3 Terrel Fahrenheit
26 Ketamin 100 mg/ml 25 KTM
27 Oksigen 12
28 Propofol inj. 1% i.v bolus 70 Fresofol 1% Fresensius
29 Atropin sulfat inj. 0,25 mg/ml 100
30 Diazepam inj. 5mg/ml 100
31 Diazepam rektal 5mg/2,5 ml 100
32 Midazolam inj. 5 mg/ml 250 Dormicum Boerhinger
33 Deksametason inj. 5 mg/ml 1200 Indofarma
34 Difenhidramin inj. 10 mg/ml 10 Phapros
35 Epinefrin inj. 0,1% 100 Phapros
36 Hidrokortison inj. 100mg/ml
37 Klorfeniramin 4 mg tab 2928 CTM
38 Loratadin tab 10 mg 1440 Promedraharjo
39 Cetirizine tab 10 mg 1440 Pertiwi Agung
40 Cetirizine syr 5 mg/5ml 150 Indofarma
41 Efedrin inj. 50 mg/ml 300 Bernofarm
42 Kalsium glukonat inj. 100 mg/ml 48 Ethica
43 Nalokson inj. 0,4 mg/ml 5 Nokoba Pratapa
44 Natrium bikarbonat inj. 8,4% 12 Meylon Otsuka
45 Neostigmin inj. 0,5 mg/ml 50 Neostigmin Pharma Care
46 Karbo adsorben tab 0,5 g 2000 Norit
47 Fenitoin 50 mg kaps 300 Ikhapharmindo
48 Fenitoin inj. 50 mg/ml 15 Mersifarma
49 Fenobarbital 30 mg tab 3000 Kimia Farma
50 Fenobarbital inj. 50 mg/ml 20 Phapros
51 Magnesium sulfat inj. 20% 120 Otsuka
52 Magnesium sulfat inj. 40% 120 Otsuka
53 Albendazol susp. 200mg/5ml 12 Indofarma
54 Amoksisilin tab 500 mg 7000 Mersifarma
55 Amoksisilin syr 125 mg/5ml 1000 Novapharin
56 Ampisilin inj. 1000 mg/vial 2000 Bernofarm
57 Cefazolin 1 g vial 120 Dexa Medica
58 Cefadroxil 500 mg caps 7000 Bernofarm
59 Cefadroxil 125 mg syr 1000 Holifarma
60 Cefixim 100 mg caps 3000 Bernofarm
61 Cefixim 100 mg/5ml syr 250 Ifars
62 Cefotaxim 500 mg/vial 1000 Hexpharm
63 Cefotaxim 1000 mg/vial 3000 Natura
64 Ceftriaxon 1000 mg/vial 1500 Natura
65 Kloramfenikol 250 mg kaps 1000 KF
66 Kloramfenikol 125 mg/5ml syr 300 Bernofarm
67 Kloramfenikol 1000 mg/vial 240 Colsancentine sanbe
68 Kloramfenikol salep mata 40 KF
69 Kotrimoksazol 480 mg tab 2000 Promedraharjo
70 Kotrimoksazol 240 mg/5ml syr 500 Sampharindo
71 Azitromisin 500 mg tab 240 Kimia Farma
72 Eritromisin 500 mg tab 1500 Indofarma
73 Eritromisin 200 mg/5ml syr 150 Phyto Kemo Agung
74 Klindamisin 300 mg kaps 1200 Indofarma
75 Spiramisin 500 mg tab 1200 Indofarma
76 Amikasin 250 mg inj. Vial Glybotic 250 mg/ml Sanbe
77 Gentamisin 40 inj. 40 mg/ml 60 Indofarma
78 Levofloxacin 500 mg tab 300 Promedraharjo
79 Levofloxacin infus 5 mg/ml 100 ml 60 Inflon
80 Ciprofloxacin 500 mg tab 7000 Bernofarm
81 Ciprofloxacin infus 2% 12 Dexa Medica
82 Meropenem 500 mg/vial 200 Bernofarm
83 Metronidazole 500 mg tab 1200 Phyto Kemo Agung
84 Metronidazole 500 mg sup 240 Flagyl
85 Metronidazole 125 mg/ml syr 60 Flagyl
86 Metronidazole infus 5 mg/ml 150 Natura
87 Metronidazole ovula 500 mg 60 Kimia Farma
 88 Flukonazol 50 mg 12 Diflucan Pfizer
89 Ketokonazol 200 mg tab 1000 Dexa Medica
90 Nistatin tab 500.000 IU 600 Phapros
91 Nistatin vaginal tablet 100.000 IU/ml 200 Phapros
92 Asiklovir 400 mg tab 3000 Sampharindo
93 Valasiklovir 500 mg tab
94 Propanolol 10 mg tab 200 Dexa Medica
95 Ergotamin 1mg + kafein 50 mg 300 Kimia Farma
96 Deksametason tab 0,5 mg 6000 Promedraharjo
97 Metilprednisolon 8 mg tab 3600 Dexa Medica
98 Asam folat 0,4 mg tab 1000 Starfolat Dexa
99 Ferro sulfat tab 300 mg 1200 Kimia Farma
100 Ferro sulfat tab 200 mg + asam folat 0,25 mg tab 2400 KF
101 Sianokobalamin (B12) 50 mcg tab 600 Afifarma
102 Sianokobalamin (B12) 500 mcg inj. 200 Lucas Djaja
103 Asam traneksamat 500 mg tab 1200 Bernofarm
104 Asam traneksamat 100 mg/ml inj. 60 Hexpharm
105 Fitomenadion (K1) 10 mg tab 600 Phapros
106 Fitomenadion (K1) 2 mg/ml inj. i.m 720 Phapros
107 Heparin Na 5000 IU/ml 5 Inviclot Fahrenheit
108 albumin serum normal (human albumin) inj. 5% Plasbumin 5% 50 ml Dipa
109 albumin serum normal (human albumin) inj. 25% Plasbumin 25% 20 ml Dipa
110 Modified fluid gelatin BM 30.000 4% 80 Gelofusin Phapros
111 Hidrogen peroksida 3% 1 liter 40 Brataco
112 Klorheksidin 5 liter 50 Onescrub
113 Klorheksidin 500 ml + dispenser 24 Onescrub
114 Iodin povidone 100 mg/ml 1 liter 80 Afifarma
115 Iodin povidone 100 mg/ml 60ml 600 KF
116 Etanol 70% 20 liter 15 Brataco
117 Etanol 70% 1 liter 40 Onemed
118 Etanol 70% 100 ml 25 Novapharin
119 Paraformaldehid 10 % larutan 5liter 2 Brataco
120 Paraformaldehid 1 g tab 200 Brataco
121 Furosemid tab 40 mg 100 Indofarma
122 Furosemid inj. 10 mg/ml 75 Indofarma
123 Hidroklorothiazide tab 12,5 mg 1000 Indofarma
124 Manitol 20% larutan infus 6 Finusolprima
125 Spironolakton 25 mg tab 100 Dexa Medica
126 Akarbose 50 mg tab 600 Dexa Medica
127 Glimepiride 2 mg tab 1500 Kimia Farma
128 Metformin 500 mg tab 2000 Bernofarm
129 Human insulin short acting penfill cartridge 100IU/ml 100 Actrapid Ferron
130 Human insulin rapid acting penfill cartridge 100IU/ml 24 Humulin R Cart Bayer
131 Etinilestradiol tab 0,05 mg 1200 Lynoral Merck Sharp
132 Noretisteron tab 5 mg 1800 Primolut N Bayer
 Kontrasepsi pil oral kombinasi : levonorgestrel
133 150mcg + etinilestradiol 30 mcg 100 KF
KB depot medroksiprogesteron asetat 25mcg +
134 estradiol sipionat 5 mg 120 Triyasa
135 Copper T 60 Andalan
136 Etonogestrel implan 68 mcg 12 Implanon Merck
137 Metilprednisolon 125 mg vial 100 Dexa Medica
138 Prednison 5 mg tab 1200 Holifarma
139 Atenolol 50 mg tab Betablok Kalbe
140 Isosorbid dinitrat sub lingual 5 mg tab 300 Indofarma
141 Isosorbid dinitrat sub lingual inj. 10 mg/ml vial 6 Farsorbid Fahrenheit
142 Diltiazem HCl 25 mg/5ml 3 Farmabes
143 Bisoprolol 5 mg tab 360 Fahrenheit
144 Amlodipin 5 mg tab 1500 Pertiwi Agung
145 Kaptopril 25 mg tab 300 Errita Farma
146 Lisinopril 10 mg tab 300 Novell
147 Metildopa 250 mg tab 300 Dopamet
148 Nifedipin 10 mg tab 6000 Dexa Medica
149 Asam asetilsalisilat 100 mg tab 600 Phapros
150 Dobutamin 50 mg/ ml 5 Doburan Dipa
151 Dopamin 40 mg/ml 5 Udopa Dipa
152 Fenofibrat 100 mg tab 300 Hexpharm
153 Gemfibrozil 300 mg tab 600 Indofarma
154 Simvastatin 10 mg tab 1440 Natura
155 Simvastatin 20 mg tab 720 Natura
156 Perak Sulfadiazine krim 1% 24 Burnazin
157 Ketokonazole krim 2% 15 g 60 Novell
158 Mikonazole krim 2% 10 g 30 Kimia Farma
159 Betametason krim 0,1% 60 Kimia Farma
160 Desoksimetason krim 0,25% 15 Dexa
161 Flusinolon asetonide 0,025% krim 40 Synarcus Ifars
162 Mometason furoat krim 0,1% 10g 70 Nulab
163 Permetrin krim 5% 12 Scabimite Galenium
164 Bedak salisil 2% 60 Rama Emerald
165 Kalium Klorida tab SR 600 mg 100 KSR Merck
166 Garam oralit kombinasi 1500 Phapros
167 Zinc tab 20 mg 2500 Indofarma
168 Zinc drop 10 mg/ml 30 Zincpro Combiphar
169 Zinc syr 20 mg/5ml 500 Zircum Mepro
170 Cairan Infus RL 500 ml 3000 Wida
171 Cairan infus Glukosa 10% 240 Wida
172 Cairan infus Glukosa 5 % 260 Wida
173 Cairan infus D5 1/2 NS 720 Wida
174 Cairan infus D5 1/4 NS 1000 Wida
175 Cairan Infus Asering 480 Otsuka
176 Cairan infus KA EN 3B 260 Otsuka
177 Cairan RD 260 Wida
178 Cairan NS 260 Wida OGB
179 Tetrakain tetes mata 0,5% 6 Pantokain Cendo
180 Gentamisin salep mata 0,3% 60 Genoint salep mata Erela
181 Gentamisin tetes mata 0,3% 80 Indofarma
182 Kloramfenikol 0,5% tetes mata 36 Erlamycetin
183 Kloramfenikol salep mata 1% 36 Kimia farma
184 Levofloxacin tetes mata 0,5% 12 Optiflox Erela
185 Betametason tetes mata 1mg/ml 12 Betam Optal ED Sanbe
186 Gliserin larutan 50% 100 ml 6 Lucas Djaja
187 Metilergometrin tab 0,125 mg 6000 Kimia farma
188 Metilergometrin ampul 0,2 mg 600 Ethica
189 Oksitosin inj. 10 UI/ml 1500 Oxytocin S Ethica
190 Alprazolam 1 mg tab 600 Kimia farma
191 Amitriptilin 25 mg tab 1500 Indofarma
192 Klorpromazin 25 mg tab 1000 Phapros
193 Atrakurium 25mg/2,5 ml inj. 10 Tracrium Glaxo
194 Antasida tab DOEN 2500 Erela
195 Antasida syr DOEN 500 Erela
196 Lanzoprazole 30 mg caps 240 Indofarma
197 Lanzoprazole inj. 30 mg/ml 120 Prosogan inj. Takeda
198 Omeprazole 20 mg caps 1440 Novapharin
199 Omeprazole 40 mg/10 ml inj. 40 Natura
200 Ranitidin tab 150 mg 3600 Dexa Medica
201 Ranitidin inj. 25mg/ml 700 Natura
202 Sukralfat 500 mg tab 300 Ulsidex Dexa
203 Sukralfat 500 mg/5ml susp 60 Ulsafate Combiphar
204 Dimenhidrinat 50 mg tab 1200 Kimia Farma
205 Domperidon 10 mg tab 1500 Novapharin
206 Domperidon 5 mg/5 ml susp 250 Novapharin
207 Domperidon 5 mg/ml tetes 70 Bernofarm
208 Metoklopramid tab 10 mg 2500 Kimia Farma
209 Metoklopramid syr 5 mg/5ml 50 Lexapram syr Molex
210 Metoklopramid 5 mg/ml drop 20 Gavistal Mepro
211 Metoklopramid 5 mg/ml inj. 250
212 Ondansetron tab 4 mg 432 Yarindo
213 Ondansetron inj. 2mg/ml 250 Indofarma
214 Antihemoroid sup 30 Kimia Farma
215 Hiosin butil bromida tab 10 mg 400 Dexa Medica
216 Hiosin butil bromida inj. 10 mg/ml 250 Otto
217 Atapulgit tab 2500 Pularex Zenith
218 Loperamide tab 1200 Ifars
219 Kaolin pektin tab 2000 Diaend Mugi
220 Bisakodil tab 5 mg 600 Novell
221 Bisakodil sup 5 mg 50 Dulcolax sup
222 Bisakodil sup 10 mg 240 Stolax sup Sanbe
223 Parafin + gliserin + fenolftalein emulsi 40 Laxadine Galenium
224 Laktulosa syr 3,335 g/5ml 60 Ikapharmindo
225 Asam ursodeoksikolik caps 250 mg 360 Novell
226 Aminofilin 200 mg tab 300 Erela
227 Aminofilin 24 mg/ml inj. 30 Lucas Djaja
228 Fenoterol HBr aerosol 100 mcg/puf 50 Berotec MDI Boeringer
229 Fenoterol HBr inhalasi 0,1% 6 Berotec solution
230 Fluticasone propionate 0,5 mg/2ml 200 Flixotide Glaxo
231 Ipratropium Bromide inhalasi 0,025% 3 Atrovent Boeringer
232 Ipratropium bromide + salbutamol nebule 120 Combivent UDV Boeringer
233 Salbutamol 2 mg tab 3000 Yarindo
234 Salbutamol 4 mg tab 3000 Kimia Farma
235 Salbutamol inhalasi 0,1% 600 Ventolin nebule
236 Teofilin tab 150 mg 200 Bronsolvan Kalbe
237 Terbutalin tab 2,5 mg 500 Molasma Molex
238 Terbutalin inj. 0,5 mg/ml 250 Relivan Novell
239 Codein tab 20 mg 1200 Kimia Farma
240 N-asetilsistein 200 mg caps 1080 Novell
241 Beractan inj 25 mg/ml intratekal 1 Survanta Abbot
242 Hepatitis B imunoglobulin 0,5 ml 36 Hyperhep B Dipa
243 Serum Anti Bisa Ular A.B.U I inj. i.m/i.v 1 Biofarma Rajawali
244 Serum Anti Tetanus inj. 1500 iu/amp 20 Biofarma Rajawali
245 Vaksin BCG 24 Biofarma Rajawali
246 Vaksin Campak 24 Biofarma Rajawali
247 Vaksin DPT + Hep B 24 Biofarma Rajawali
248 Vaksin DTP 24 Biofarma Rajawali
249 Vaksin TT 6 Biofarma Rajawali
250 Vaksin polio 120 Biofarma Rajawali
251 Oksimetazolin tetes hidung 0,025% 12 Ilaidin drop Merck
252 Ofloxacin tetes telinga 3% 12 Tarivid Otic Kalbe
253 Asam askorbat 250 mg tab 1000 Kimia Farma
254 Asam askorbat 50 mg tab 10000 Kimia Farma
255 Vitamin B6 10 mg tab 1200 Kimia Farma
256 Retinol (vitamin A) 100.000 IU 100 Kimia Farma
257 Retinol (vitamin A) 200.000 IU 100 Kimia Farma
258 Sianokobalamin (vit. B12) 50 mcg 1200 Kimia Farma
259 Tiamin (vit. B1) 50 mg 1000 Kimia Farma
260 vitamin B kompleks 8000 Kimia Farma
261 Kalsium laktat 500 mg tab 5000 Afifarma
262 Ergokalsiferol (vitamin D3/D2) 50.000 UI kapsul 1440 D-Fit FT Gracia Pharm.
Total Perencanaan Pengadaan Rutin Tahun 2015
Pengadaan obat baru 5% dari Total Perencanaan
Total Perencanaan Pengadaan Obat tahun 2015
 Data Pendukung Anggaran Harga Harga +30%
E-catalogue 9,652,500.00 49,500.00 64350
E-catalogue 572,000.00 88,000.00 114400
E-catalogue 1,625,000.00 1,250.00 1625
E-catalogue 1,891,500.00 9,700.00 12610
E-catalogue 2,398,500.00 12,300.00 15990
910,000.00 350.00 455
E-catalogue 936,000.00 180.00 234
E-catalogue 195,000.00 150.00 195
E-catalogue 487,500.00 250.00 325
E-catalogue 2,535,000.00 6,500.00 8450
E-catalogue 14,820,000.00 9,500.00 12350
E-catalogue 5,148,000.00 6,600.00 8580
E-catalogue 975,000.00 250.00 325
E-catalogue 1,040,000.00 80.00 104
E-catalogue 3,900,000.00 1,500.00 1950
E-catalogue 6,760,000.00 5,200.00 6760
E-catalogue 4,160,000.00 6,400.00 8320
390,000.00 150.00 195
E-catalogue 9,360,000.00 30,000.00 39000
2,340,000.00 120,000.00 156000
E-catalogue 2,028,000.00 1,300.00 1690
E-catalogue 624,000.00 2,000.00 2600
E-catalogue 163,800.00 42,000.00 54600
E-catalogue 565,500.00 145,000.00 188500
E-catalogue 1,053,000.00 270,000.00 351000
E-catalogue 3,900,000.00 120,000.00 156000
46,800,000.00 3,000,000.00 3900000
E-catalogue 1,456,000.00 16,000.00 20800
208,000.00 1,600.00 2080
1,690,000.00 13,000.00 16900
1,498,250.00 11,525.00 14982.5
E-catalogue 3,919,500.00 12,060.00 15678
E-catalogue 2,464,800.00 1,580.00 2054
E-catalogue 13,650.00 1,050.00 1365
E-catalogue 1,053,000.00 8,100.00 10530
0.00 0
190,320.00 50.00 65
E-catalogue 288,288.00 154.00 200.2
E-catalogue 338,832.00 181.00 235.3
E-catalogue 1,559,805.00 7,999.00 10398.7
E-catalogue 5,066,100.00 12,990.00 16887
E-catalogue 486,720.00 7,800.00 10140
E-catalogue 400,400.00 61,600.00 80080
E-catalogue 96,720.00 6,200.00 8060
E-catalogue 617,500.00 9,500.00 12350
130,000.00 50.00 65
E-catalogue 51,870.00 133.00 172.9
E-catalogue 394,875.00 20,250.00 26325
390,000.00 100.00 130
E-catalogue 46,800.00 1,800.00 2340
702,000.00 4,500.00 5850
1,014,000.00 6,500.00 8450
E-catalogue 60,044.40 3,849.00 5003.7
E-catalogue 2,375,100.00 261.00 339.3
E-catalogue 3,178,500.00 2,445.00 3178.5
E-catalogue 13,260,000.00 5,100.00 6630
E-catalogue 2,574,000.00 16,500.00 21450
E-catalogue 4,631,900.00 509.00 661.7
E-catalogue 6,364,800.00 4,896.00 6364.8
E-catalogue 3,350,100.00 859.00 1116.7
E-catalogue 2,860,000.00 8,800.00 11440
E-catalogue 6,240,000.00 4,800.00 6240
E-catalogue 11,505,000.00 2,950.00 3835
E-catalogue 6,435,000.00 3,300.00 4290
E-catalogue 323,700.00 249.00 323.7
E-catalogue 1,435,200.00 3,680.00 4784
E-catalogue 2,265,120.00 7,260.00 9438
E-catalogue 83,200.00 1,600.00 2080
E-catalogue 358,800.00 138.00 179.4
E-catalogue 1,408,550.00 2,167.00 2817.1
E-catalogue 1,404,000.00 4,500.00 5850
E-catalogue 1,813,500.00 930.00 1209
E-catalogue 1,501,500.00 7,700.00 10010
E-catalogue 862,680.00 553.00 718.9
E-catalogue 2,338,440.00 1,499.00 1948.7
E-catalogue 0.00 50,500.00 65650
E-catalogue 265,122.00 3,399.00 4418.7
E-catalogue 205,920.00 528.00 686.4
E-catalogue 3,120,000.00 40,000.00 52000
E-catalogue 2,320,500.00 255.00 331.5
E-catalogue 202,800.00 13,000.00 16900
E-catalogue 11,689,600.00 44,960.00 58448
E-catalogue 249,600.00 160.00 208
E-catalogue 1,035,840.00 3,320.00 4316
3,900,000.00 50,000.00 65000
E-catalogue 1,942,200.00 9,960.00 12948
E-catalogue 300,300.00 3,850.00 5005
E-catalogue 75,847.20 4,862.00 6320.6
E-catalogue 390,000.00 300.00 390
E-catalogue 499,200.00 640.00 832
E-catalogue 124,800.00 480.00 624
E-catalogue 1,310,400.00 336.00 436.8
0.00 0
E-catalogue 16,900.00 65.00 84.5
E-catalogue 52,650.00 135.00 175.5
E-catalogue 483,600.00 62.00 80.6
E-catalogue 1,404,000.00 300.00 390
E-catalogue 109,200.00 84.00 109.2
343,200.00 220.00 286
E-catalogue 156,000.00 50.00 65
E-catalogue 44,460.00 57.00 74.1
E-catalogue 280,280.00 1,078.00 1401.4
1,872,000.00 1,200.00 1560
E-catalogue 260,052.00 3,334.00 4334.2
E-catalogue 491,400.00 630.00 819
E-catalogue 3,198,312.00 3,417.00 4442.1
E-catalogue 278,850.00 42,900.00 55770
E-catalogue 0.00 283,000.00 367900
E-catalogue 0.00 321,552.00 418017.6
E-catalogue 7,488,000.00 72,000.00 93600
780,000.00 15,000.00 19500
E-catalogue 27,300,000.00 420,000.00 546000
E-catalogue 1,950,000.00 62,500.00 81250
E-catalogue 3,859,336.00 37,109.00 48241.7
E-catalogue 4,678,440.00 5,998.00 7797.4
6,825,000.00 350,000.00 455000
E-catalogue 1,118,000.00 21,500.00 27950
E-catalogue 81,250.00 2,500.00 3250
292,500.00 112,500.00 146250
195,000.00 750.00 975
E-catalogue 11,050.00 85.00 110.5
E-catalogue 178,327.50 1,829.00 2377.7
46,800.00 36.00 46.8
E-catalogue 483,600.00 62,000.00 80600
E-catalogue 40,950.00 315.00 409.5
E-catalogue 608,400.00 780.00 1014
E-catalogue 850,200.00 436.00 566.8
E-catalogue 292,500.00 112.50 146.25
E-catalogue 9,945,000.00 76,500.00 99450
E-catalogue 2,375,100.00 76,125.00 98962.5
E-catalogue 2,121,600.00 1,360.00 1768
E-catalogue 6,126,120.00 2,618.00 3403.4
E-catalogue 271,570.00 2,089.00 2715.7

E-catalogue 834,600.00 5,350.00 6955

1,772,706.00 22,727.00 29545.1
E-catalogue 2,008,952.40 128,779.00 167412.7
E-catalogue 2,496,000.00 19,200.00 24960
E-catalogue 177,840.00 114.00 148.2
E-catalogue 0.00 700.00 910
E-catalogue 34,320.00 88.00 114.4
E-catalogue 257,400.00 33,000.00 42900
E-catalogue 182,001.30 46,667.00 60667.1
E-catalogue 301,860.00 645.00 838.5
E-catalogue 364,650.00 187.00 243.1
E-catalogue 32,760.00 84.00 109.2
E-catalogue 234,000.00 600.00 780
E-catalogue 312,000.00 800.00 1040
E-catalogue 858,000.00 110.00 143
E-catalogue 90,480.00 116.00 150.8
E-catalogue 173,550.00 26,700.00 34710
E-catalogue 63,960.00 9,840.00 12792
E-catalogue 419,250.00 1,075.00 1397.5
E-catalogue 225,420.00 289.00 375.7
E-catalogue 316,368.00 169.00 219.7
E-catalogue 365,976.00 391.00 508.3
E-catalogue 717,600.00 23,000.00 29900
E-catalogue 366,600.00 4,700.00 6110
E-catalogue 117,000.00 3,000.00 3900
E-catalogue 118,560.00 1,520.00 1976
E-catalogue 194,668.50 9,983.00 12977.9
E-catalogue 124,800.00 2,400.00 3120
E-catalogue 1,621,620.00 17,820.00 23166
E-catalogue 179,010.00 11,475.00 14917.5
E-catalogue 97,500.00 1,250.00 1625
E-catalogue 205,400.00 1,580.00 2054
E-catalogue 444,600.00 228.00 296.4
E-catalogue 1,540,500.00 474.00 616.2
E-catalogue 500,760.00 12,840.00 16692
E-catalogue 4,810,000.00 7,400.00 9620
E-catalogue 31,200,000.00 8,000.00 10400
E-catalogue 1,778,400.00 5,700.00 7410
E-catalogue 1,757,600.00 5,200.00 6760
E-catalogue 7,207,200.00 7,700.00 10010
E-catalogue 10,010,000.00 7,700.00 10010
E-catalogue 5,616,000.00 9,000.00 11700
E-catalogue 3,380,000.00 10,000.00 13000
E-catalogue 2,342,340.00 6,930.00 9009
E-catalogue 1,588,600.00 4,700.00 6110
E-catalogue 89,700.00 11,500.00 14950
E-catalogue 202,800.00 2,600.00 3380
E-catalogue 332,176.00 3,194.00 4152.2
234,000.00 5,000.00 6500
E-catalogue 74,880.00 1,600.00 2080
E-catalogue 203,860.80 13,068.00 16988.4
E-catalogue 391,653.60 25,106.00 32637.8
E-catalogue 41,597.40 5,333.00 6932.9
E-catalogue 1,201,200.00 154.00 200.2
E-catalogue 2,145,000.00 2,750.00 3575
E-catalogue 4,290,000.00 2,200.00 2860
E-catalogue 181,740.00 233.00 302.9
E-catalogue 218,400.00 112.00 145.6
E-catalogue 88,400.00 68.00 88.4
E-catalogue 260,000.00 20,000.00 26000
E-catalogue 234,000.00 72.00 93.6
E-catalogue 1,404,000.00 2,160.00 2808
E-catalogue 147,576.00 473.00 614.9
1,716,000.00 11,000.00 14300
E-catalogue 394,992.00 211.00 274.3
E-catalogue 1,872,000.00 36,000.00 46800
E-catalogue 561,600.00 120.00 156
E-catalogue 1,037,400.00 1,140.00 1482
E-catalogue 165,360.00 424.00 551.2
E-catalogue 1,047,150.00 13,425.00 17452.5
E-catalogue 162,240.00 104.00 135.2
E-catalogue 325,650.00 167.00 217.1
E-catalogue 1,083,225.00 3,333.00 4332.9
E-catalogue 1,419,600.00 15,600.00 20280
E-catalogue 351,000.00 108.00 140.4
E-catalogue 169,000.00 2,600.00 3380
E-catalogue 137,280.00 5,280.00 6864
1,787,500.00 5,500.00 7150
profilaks untuk kemo 402,105.60 716.00 930.8
profilaks untuk kemo 780,000.00 2,400.00 3120
E-catalogue 780,000.00 20,000.00 26000
E-catalogue 247,000.00 475.00 617.5
E-catalogue 1,462,500.00 4,500.00 5850
E-catalogue 617,500.00 190.00 247
tidak digunakan untuk anak 138,840.00 89.00 115.7
208,000.00 80.00 104
E-catalogue 291,720.00 374.00 486.2
E-catalogue 324,350.00 4,990.00 6487
E-catalogue 1,886,040.00 6,045.00 7858.5
E-catalogue 647,400.00 12,450.00 16185
1,950,000.00 25,000.00 32500
1,965,600.00 4,200.00 5460
E-catalogue 31,200.00 80.00 104
E-catalogue 149,058.00 3,822.00 4968.6
hanya serangan asma akut 4,738,500.00 72,900.00 94770
hanya serangan asma akut 916,500.00 117,500.00 152750
E-catalogue 3,358,420.00 12,917.00 16792.1
E-catalogue 351,000.00 90,000.00 117000
E-catalogue 934,440.00 5,990.00 7787
E-catalogue 230,100.00 59.00 76.7
E-catalogue 347,100.00 89.00 115.7
E-catalogue 5,148,000.00 6,600.00 8580
E-catalogue 65,000.00 250.00 325
E-catalogue 64,350.00 99.00 128.7
E-catalogue 1,300,000.00 4,000.00 5200
E-catalogue 1,716,000.00 1,100.00 1430
hanya pasien rawat inap 1,544,400.00 1,100.00 1430
hanya untuk IRDS neonatus 4,160,000.00 3,200,000.00 4160000
E-catalogue 62,150,400.00 1,328,000.00 1726400
455,000.00 350,000.00 455000
3,380,000.00 130,000.00 169000
1,560,000.00 50,000.00 65000
1,560,000.00 50,000.00 65000
1,560,000.00 50,000.00 65000
1,560,000.00 50,000.00 65000
390,000.00 50,000.00 65000
7,154,628.00 45,863.00 59621.9
E-catalogue 429,780.00 27,550.00 35815
E-catalogue 756,600.00 48,500.00 63050
E-catalogue 206,700.00 159.00 206.7
E-catalogue 1,235,000.00 95.00 123.5
E-catalogue 156,000.00 100.00 130
E-catalogue 33,800.00 260.00 338
E-catalogue 59,670.00 459.00 596.7
E-catalogue 88,920.00 57.00 74.1
E-catalogue 130,000.00 100.00 130
E-catalogue 1,112,800.00 107.00 139.1
E-catalogue 455,000.00 70.00 91
E-catalogue 1,216,800.00 650.00 845
574,296,695.70
28,714,834.79 574,296,695.70
603,011,530.49
 FORMULARIUM BPJS RSIA NUN

SUB KELAS TERAPI/NAMA

KELAS TERAPI Keterangan
GENERIK/SEDIAAN/KEKUATAN

1. ANALGESIK, ANTIPIRETIK, ANTIINFLAMASI NON STEROID,

ANTIPIRAI
1 Fentanyl inj. 0,05mg/ml
2 Fentanyl patch 12,5 mcg/jam
3 Kodein 20 mg tab
4 Morfin inj. 10 mg/ml
5 Pethidin inj. 50mg/ml
6 Asam mefenamat 250 mg
7 Asam mefenamat 500 mg
8 Ibuprofen 200 mg tab
9 Ibuprofen 400 mg tab
10 Ibuprofen syr 100 mg/5ml
11 Ketoprofen 100 mg
12 Ketorolak inj. 30 mg/ml
13 Natrium diklofenak 50 mg tab
14 Parasetamol tab 500 mg
15 Parasetamol syr 120 mg/5ml
16 Parasetamol drop 60mg/0,6 ml
17 Tramadol inj. 10 mg/ml
18 Alopurinol 100 mg tab
2. ANESTETIK
1 Bupivakain heavy spinal inj.
2 Etil klorida spray
3 Lidokain 2% ampul
4 Lidocaine 2 % + Epinefrin 1:80000, amp 2 ml
5 Lidocaine jeli 2%
6 Lidocain spray 10%
7 Isofluran
8 Ketamin 100 mg/ml
9 Oksigen
10 Propofol inj. 1% i.v bolus
3. OBAT untuk PROSEDUR PRE OPERATIF
1 Atropin sulfat inj. 0,25 mg/ml
2 Diazepam inj. 5mg/ml
3 Midazolam inj. 5 mg/ml
4. ANTIALERGI dan OBAT untuk ANAFILAKSIS
1 Deksametason inj. 5 mg/ml
2 Difenhidramin inj. 10 mg/ml
3 Epinefrin inj. 0,1%
4 Hidrokortison inj. 100mg/ml
5 Klorfeniramin 4 mg tab
6 Loratadin tab 10 mg
7 Cetirizine tab 10 mg
8 Cetirizine syr 5 mg/5ml
5. ANTIDOT dan OBAT LAIN untuk KERACUNAN
 1 Atropin sulfat inj. 0,25 mg/ml
2 Efedrin inj. 50 mg/ml
3 Kalsium glukonat inj. 100 mg/ml
4 Nalokson inj. 0,4 mg/ml
5 Natrium bikarbonat inj. 8,4%
6 Neostigmin inj. 0,5 mg/ml
7 Karbo adsorben tab 0,5 g
6. ANTIEPILEPSI - ANTIKONVULSI
1 Diazepam inj. 5mg/ml
2 Diazepam rektal 5mg/2,5 ml
3 Fenitoin 50 mg kaps
4 Fenitoin inj. 50 mg/ml
5 Fenobarbital 30 mg tab
6 Fenobarbital inj. 50 mg/ml
7 Magnesium sulfat inj. 20%
8 Magnesium sulfat inj. 40%
7. ANTIINFEKSI
1 Albendazol susp. 200mg/5ml
2 Amoksisilin tab 500 mg
3 Amoksisilin syr 125 mg/5ml
4 Ampisilin inj. 1000 mg/vial
5 Cefazolin 1 g vial
6 Cefadroxil 500 mg caps
7 Cefadroxil 125 mg syr
8 Cefixim 100 mg caps
9 Cefixim 100 mg/5ml syr
10 Cefotaxim 500 mg/vial
11 Cefotaxim 1000 mg/vial
12 Ceftriaxon 1000 mg/vial
13 Kloramfenikol 250 mg kaps
14 Kloramfenikol 125 mg/5ml syr
15 Kloramfenikol 1000 mg/vial
16 Kloramfenikol salep mata
17 Kotrimoksazol 480 mg tab
18 Kotrimoksazol 240 mg/5ml syr
19 Azitromisin 500 mg tab
20 Eritromisin 500 mg tab
21 Eritromisin 200 mg/5ml syr
22 Klindamisin 300 mg kaps
23 Spiramisin 500 mg tab
24 Amikasin 250 mg inj. Vial
25 Gentamisin 40 inj. 40 mg/ml
26 Levofloxacin 500 mg tab
27 Levofloxacin infus 5 mg/ml 100 ml
28 Ciprofloxacin 500 mg tab
29 Ciprofloxacin infus 2%
30 Meropenem 500 mg/vial
31 Metronidazole 500 mg tab
32 Metronidazole 500 mg sup
33 Metronidazole 125 mg/ml syr
34 Metronidazole infus 5 mg/ml
 35 Metronidazole ovula 500 mg
36 Flukonazol 50 mg
37 Ketokonazol 200 mg tab
38 Nistatin tab 500.000 IU
39 Nistatin vaginal tablet 100.000 IU/ml
40 Asiklovir 400 mg tab
41 Valasklovir 500 mg tab
8. ANTIMIGREN
1 Ergotamin 1mg + kafein 50 mg
9. OBAT yang MEMPENGARUHI DARAH
9.1 ANTIANEMI
1 Asam folat 0,4 mg tab
2 Ferro sulfat tab 300 mg
3 Ferro sulfat tab 200 mg + asam folat 0,25 mg tab
4 Sianokobalamin (B12) 50 mcg tab
5 Sianokobalamin (B12) 500 mcg inj.
9.2 OBAT yang MEMPENGARUHI KOAGULASI
1 Asam traneksamat 500 mg tab
2 Asam traneksamat 100 mg/ml inj.
3 Fitomenadion (K1) 10 mg tab
4 Fitomenadion (K1) 2 mg/ml inj. i.m
5 Heparin Na 5000 IU/ml
9.3 PENGGANTI PLASMA dan PLASMA EKSPANDER
1 albumin serum normal (human albumin) inj. 5%
2 albumin serum normal (human albumin) inj. 25%
3 Modified fluid gelatin BM 30.000 4%
10. ANTISEPTIK dan DISINFEKTAN
1 Hidrogen peroksida 3% 1 liter
2 Klorheksidin 5 liter
3 Klorheksidin 500 ml + dispenser
4 Iodin povidone 100 mg/ml 1 liter
5 Iodin povidone 100 mg/ml 60ml
6 Etanol 70% 20 liter
7 Etanol 70% 1 liter
8 Etanol 70% 100 ml
9 Paraformaldehid 10 % larutan 5liter
10 Paraformaldehid 1 g tab
11. DIURETIK
1 Furosemid tab 40 mg
2 Furosemid inj. 10 mg/ml
3 Hidroklorothiazide tab 12,5 mg
4 Manitol 20% larutan infus
5 Spironolakton 25 mg tab
12. ANTIDIABETES
1 Akarbose 50 mg tab
2 Glimepiride 2 mg tab
3 Metformin 500 mg tab
4 Human insulin short acting penfill cartridge 100IU/ml
5 Human insulin rapid acting penfill cartridge 100IU/ml
13. HORMON KELAMIN dan OBAT yang MEMPENGARUHI FERTILITAS
1 Etinilestradiol tab 0,05 mg
 2 Noretisteron tab 5 mg
14. Kontrasepsi
Kontrasepsi pil oral kombinasi : levonorgestrel 150mcg +
1 etinilestradiol 30 mcg
KB depot medroksiprogesteron asetat 25mcg + estradiol
2 sipionat 5 mg
3 Copper T
4 Etonogestrel implan 68 mcg
15. KORTIKOSTEROID
1 Deksametason inj. 5 mg/ml
2 Deksamethasone 0,5 mg tab
3 Metilprednisolon 125 mg vial
4 Metilprednisolon 8 mg tab
5 Prednison 5 mg tab
16. OBAT KARDIOVASKULER
16.1 ANTIANGINA
1 Isosorbid dinitrat sub lingual 5 mg tab
2 Isosorbid dinitrat sub lingual inj. 10 mg/ml
3 Atenolol 50 mg tab
16.2 ANTIARITMIA
1 Diltiazem HCl 25 mg/5ml
16.3 ANTIHIPERTENSI
1 Bisoprolol 5 mg tab
2 Amlodipin 5 mg tab
3 Kaptopril 25 mg tab
4 Lisinopril 10 mg tab
5 Metildopa 250 mg tab
6 Nifedipin 10 mg tab
16.4 ANTIAGREGASI PLATELET
1 Asam asetilsalisilat 100 mg tab
16.5 OBAT untuk SYOK KARDIOGENIK dan SEPSIS
1 Dobutamin 50 mg/ ml
2 Dopamin 40 mg/ml
3 Epinefrin inj. 0,1%
16.6 ANTIHIPERLIPIDEMIA
1 Fenofibrat 100 mg tab
2 Gemfibrozil 300 mg tab
3 Simvastatin 10 mg tab
4 Simvastatin 20 mg tab
17. OBAT TOPIKAL untuk KULIT
1 Perak Sulfadiazine krim 1%
2 Ketokonazole krim 2% 15 g
3 Mikonazole krim 2% 10 g
4 Betametason krim 0,1%
5 Desoksimetason krim 0,25%
6 Flusinolon asetonide 0,025% krim
7 Mometason furoat krim 0,1% 10g
8 Permetrin krim 5%
9 Bedak salisil 2%
18. LARUTAN ELEKTROLIT, NUTRISI, dan LAIN-LAIN
1 Kalium Klorida tab SR 600 mg
 2 Garam oralit kombinasi
3 Zinc tab 20 mg
4 Zinc drop 10 mg/ml
5 Zinc syr 20 mg/5ml
6 Cairan Infus RL 500 ml
7 Cairan infus Glukosa 10%
8 Cairan infus Glukosa 5 %
9 Cairan infus D5 1/2 NS
10 Cairan infus D5 1/4 NS
11 Cairan Infus Asering
12 Cairan infus KA EN 3B
13 Cairan RD
14 Cairan NS
19. OBAT untuk MATA
1 Tetrakain tetes mata 0,5%
2 Gentamisin salep mata 0,3%
3 Gentamisin tetes mata 0,3%
4 Kloramfenikol 0,5% tetes mata
5 Kloramfenikol salep mata 1%
6 Levofloxacin tetes mata 0,5%
7 Betametason tetes mata 1mg/ml
8 Gliserin larutan 50% 100 ml
20. OKSITOSIK
1 Metilergometrin tab 0,125 mg
2 Metilergometrin ampul 0,2 mg
3 Oksitosin inj. 10 UI/ml
21. ANTIANSIETAS
1 Alprazolam 1 mg tab
2 Diazepam 2 mg tab
3 Diazepam inj. 5mg/ml
22. ANTIDEPRESI dan ANTIMANIA
1 Amitriptilin 25 mg tab
23. ANTIPSIKOSIS
1 Klorpromazin 25 mg tab
24. RELAKSAN OTOT PERIFER dan PENGHAMBAT KOLINESTERASE
24.1 PENGHAMBAT dan PEMACU TRANSMISI NEUROMUSKULER
1 Atrakurium 25mg/2,5 ml inj.
2 Neostigmin inj. 0,5 mg/ml
24.2 OBAT untuk MIASTENIA GRAVIS
1 Neostigmin inj. 0,5 mg/ml
25. OBAT untuk SALURAN CERNA
25.1 ANTASIDA dan ANTIULKUS
1 Antasida tab DOEN
2 Antasida syr DOEN
3 Lanzoprazole 30 mg caps
4 Lanzoprazole inj. 30 mg/ml
5 Omeprazole 20 mg caps
6 Omeprazole 40 mg/10 ml inj.
7 Ranitidin tab 150 mg
8 Ranitidin inj. 25mg/ml
9 Sukralfat 500 mg tab
 10 Sukralfat 500 mg/5ml susp
25.2 ANTIEMETIK
1 Dimenhidrinat 50 mg tab
2 Domperidon 10 mg tab
3 Domperidon 5 mg/5 ml susp
4 Domperidon 5 mg/ml tetes
5 Metoklopramid tab 10 mg
6 Metoklopramid syr 5 mg/5ml
7 Metoklopramid 5 mg/ml drop
8 Metoklopramid 5 mg/ml inj.
9 Ondansetron tab 4 mg profilaks untuk kemo
10 Ondansetron inj. 2mg/ml profilaks untuk kemo
25.3 ANTIHEMOROID
1 Antihemoroid sup
25.4 ANTISPASMODIK
1 Hiosin butil bromida tab 10 mg
2 Hiosin butil bromida inj. 10 mg/ml
25.5 OBAT untuk DIARE
1 Atapulgit tab
2 Loperamide tab tidak digunakan untuk anak
3 Kaolin pektin tab
4 Garam oralit kombinasi
5 Zinc tab 20 mg
6 Zinc syr 20 mg/5ml
25.6 KATARTIK
1 Bisakodil tab 5 mg
2 Bisakodil sup 5 mg
3 Bisakodil sup 10 mg
4 Parafin + gliserin + fenolftalein emulsi
5 Laktulosa syr 3,335 g/5ml
25.7 LAIN-LAIN
1 Asam ursodeoksikolik caps 250 mg
26. OBAT untuk SALURAN NAPAS
26.1 ANTIASMA
1 Aminofilin 200 mg tab
2 Aminofilin 24 mg/ml inj.
3 Fenoterol HBr aerosol 100 mcg/puff hanya serangan asma akut
4 Fenoterol HBr inhalasi 0,1% hanya serangan asma akut
5 Fluticasone propionate 0,5 mg/2ml
6 Ipratropium Bromide inhalasi 0,025%
7 Ipratropium bromide + salbutamol nebule
8 Salbutamol 2 mg tab
9 Salbutamol 4 mg tab
10 Salbutamol inhalasi 0,1%
11 Teofilin tab 150 mg
12 Terbutalin tab 2,5 mg
13 Terbutalin inj. 0,5 mg/ml
14 Deksamethasone 0,5 mg tab
15 Methylprednisololon 8 mg tab
16 Epinefrin inj. 0,1%
26.2 ANTITUSIF
 1 Codein tab 20 mg
26.3 EKSPEKTORAN
2 N-asetilsistein 200 mg caps hanya pasien rawat inap
26.5 LAIN-LAIN
1 Beractan inj 25 mg/ml intratekal hanya untuk IRDS neonatus
27. OBAT yang MEMPENGARUHI SISTEM IMUN
27.1 SERUM dan IMUNOGLOBULIN
1 Hepatitis B imunoglobulin 0,5 ml
2 Serum Anti Bisa Ular A.B.U I inj. i.m/i.v
3 Serum Anti Tetanus inj. 1500 iu/amp
27.2 VAKSIN
1 Vaksin BCG
2 Vaksin Campak
3 Vaksin DPT + Hep B
4 Vaksin DTP
5 Vaksin TT
6 Vaksin polio
28. OBAT untuk TELINGA, HIDUNG, dan TENGGOROKAN
1 Oksimetazolin tetes hidung 0,025%
2 Ofloxacin tetes telinga 3%
29 VITAMIN dan MINERAL
1 Asam askorbat 250 mg tab
2 Asam askorbat 50 mg tab
3 Vitamin B6 10 mg tab
4 Retinol (vitamin A) 100.000 IU
5 Retinol (vitamin A) 200.000 IU
6 Sianokobalamin (vit. B12) 50 mcg tab
7 Tiamin (vit. B1) 50 mg tab
8 vitamin B kompleks tab
9 Ferro sulfat tab 300 mg tab
10 Ferro sulfat tab 200 mg + asam folat 0,25 mg tab
11 Kalsium glukonat inj. 100 mg/ml
12 Kalsium laktat 500 mg tab
13 Ergokalsiferol (vitamin D3/D2) 50.000 UI kapsul

Surabaya, Februari 2015

Mengetahui, Mengajukan,
Wakil Direktur Pelayanan Medik Ka. Instalasi Farmasi

dr. Alfita Widyaningrum Karina A.S., S.Farm., Apt.

Menyetujui,
Direktur RSIA NUN
 dr. Numbi Mediatmapratia

Keterangan :
1. Lampiran Persetujuan Dokter di RSIA NUN Surabaya Atas Penggunaan Formularium BPJS