Balige, 21 Juni 2015

Nomor : 441 / /Pusk/VI/2015 Kepada Yth:

Lampiran:- Kepala Dinas Kesehatan Toba Samosir
Perihal : Daftar Usulan Rencana Kebutuhan BMHP/Obat c/q. Ka.Bid JP2RK
Bulan Januari Tahun 2015 di-
Balige,

Bersama ini kami sampaikan Kepada ibu Ka. Dinas Kesehatan usulan obat / BMHP BPJS dari UPT. Puskesmas
Tandang Buhit Balige untuk bulan Januari 2015

No Nama Obat/BMHP Kemasan Penyedia Volume Harga Satuan Total Harga

1 Amoksilin kapsul/kaplet/tab 500mg Kotak @ 10x10 Tab PT. Mersifarma Tirmaku 15,000 Rp 270 Rp 4,050,000
2 Amoksilin sirup kering 125mg/5ml Btl @ 60 ml PT. Novapharin 1,200 Rp 2,500 Rp 3,000,000

3 Antasida doen II suspensi,kombinasi : Btl 60 ml PT. Lucas Djaja 300 Rp 2,200 Rp 660,000
Aluminium hidroksida 200 mg
4 Albendazol tab 400mg Ktk 5x6 Tablet PT. Kima Farma 900 Rp 350 Rp 315,000
5 Alopurinol 100mg Box, 10 Strips @ 10 Tab PT. Pertiwi Agung 1,200 Rp 88 Rp 105,600
6 Alprazolam 0,5mg 1box 10 strip x 10 Tab PT. Otto Pharmaceuticals 1,200 Rp 180 Rp 216,000
7 Amlodipine 5mg Box, 3strips @ 10 tablets PT. Pertiwi Agung 9,000 Rp 192 Rp 1,728,000

8 Antimigraen (Ergotamin tartarat 1 mg Btl 100 tablet PT. Kima Farma 1,200 Rp 142 Rp 170,400
+ kofein 50mg
9 Asam askorbat(Vit. C ) tab 50mg Dus, 10 strip x 10 tab PT. Kima Farma 18,000 Rp 100 Rp 1,800,000
10 Amoksilin kapsul/tablet 250mg Dus, 10 bliser @ 12Kapsul PT. Indofarma 14,400 Rp 210 Rp 3,024,000
11 Atapulgit tab 600mg Dus 5 strip @ 10 tablet PT. Zenith Pharceuticals 600 Rp 200 Rp 120,000
12 Bisoprolol tab 5mg Box 3 x 10 tab PT. Pratapa Nirmala 540 Rp 669 Rp 361,260
13 Budesonid-formoteral INH 200 mg Dus,Turbuhaler@120dosi PT. Astrazeneca Indonesia 17 Rp 93,000 Rp 1,581,000
14 Diazepam rektal 10mg/2,5ml (stesolid) Dus, 5 alubag@tube@2,5ml PT. Actavis Indonesia 60 Rp 17,604 Rp 1,056,240
15 Dexametason tablet 0,5 mg Dus, 10 strip @ 10 tab PT. Promedrahardjo Farmasi 6,000 Rp 64 Rp 384,000
16 Digoksin tab 0,25 mg Box 10 x 10 tab PT. Yarindo Farmatam 600 Rp 100 Rp 60,000
17 Eritromisin 500 mg Dus, 10 blister @ 10 kss PT. Indofarma 1,800 Rp 976 Rp 1,756,800
18 Efedrin inj 50 mg/ml Ampul @ 1 ml PT. Bernofarm 220 Rp 13,000 Rp 2,860,000
19 Epinerfrin inj 1 mg Dus @ 30 Ampul PT. Phapros Tbk 300 Rp 8,505 Rp 2,551,500
20 Eritromicin sirup 200/5 ml Botol @60 ml PT. Phyto Kemo Agung Farma 300 Rp 7,893 Rp 2,367,900
21 Ergokalsiferol Suspensi 10.000 IU Dus, Botol Plastik @ 100ml PT. Gracia Pharmindo 280 Rp 8,000 Rp 2,240,000
22 Ergokalsiferol 50.000 IU Dus 3 strip @ flash tablet PT. Gracia Pharmindo 530 Rp 680 Rp 360,400
23 Furosemid 40% mg Dus, 10 strip @ 10 tab PT. Indofarma 1,300 Rp 94 Rp 122,200
24 Fenitoin Na inj 100 mg Botol @ 100 PT. Ikapharmindo 580 Rp 140 Rp 81,200
25 Garam oralit Dus @ 100 Sachet PT. Phapros Tbk 520 Rp 303 Rp 157,560
26 Gentamicin 0,3 % tetes mata Dus, Botol Plastik 5 ml PT. Indofarma 123 Rp 3,353 Rp 412,419
27 Gliklazid 30 mg Dus, 6 strip@10 tab lepas PT. Pradja Pharin 660 Rp 638 Rp 421,080
28 Hidrocortison grean 1 % Tube @ 5 ml PT. Martin Liza Farmasi 113 Rp 2,699 Rp 304,987
29 Haloperidol tab 1,5 mg Dus, 10 blister @ 10 tablet PT. Indofarma 600 Rp 72 Rp 43,200
30 kandesartan tab 8mg Dus, 3 blister @ 10 tablet PT. Dexa Medika 590 Rp 3,255 Rp 1,920,450
31 Kaptopril Scored 12,5 mg Dus, 10 strip @ 10 tab PT. Indofarma 5,900 Rp 62 Rp 365,800
32 Kaptopril Scored 25 mg Dus, 10 strip @ 10 tab PT. Eritta Pharma 5,900 Rp 89 Rp 525,100
33 Klobazam 10 mg Dus, 10 strip @ 10 tab PT. Dexa Medika 600 Rp 900 Rp 540,000
34 Kodein tab 10 mg Ktk 10x10 tablet PT. Kima Farma 1,200 Rp 525 Rp 630,000
35 Karbamazepin tab 200 mg Dus, 10 blister @ 10 tablet PT. Indofarma 1,200 Rp 257 Rp 308,400
36 Klopidogrel tab 75 mg Ktk 3x10 tablet PT. Kima Farma 180 Rp 3,500 Rp 630,000
37 Klorpromazine 100 mg Dus @ 10x10's PT. Phapros Tbk 1,200 Rp 158 Rp 189,600
38 Lansoprazole cap 30 mg Dus, 2 strip @ 10 kapsul PT. Indofarma 3,000 Rp 47 Rp 141,000
39 Lidocain inj 2 %` Dus, 100 ampul @ 2 ml PT. Bernofarm 800 Rp 87 Rp 69,600
40 Lisinopril tab 5 mg Box, 3 strip @ 10 tablet PT. Novell Pharmaeutical 540 Rp 36 Rp 19,440
41 Metil Prednisolon 4 mg Dus, 10 blister @ 10 tablet PT. Natura Laboratoria Prima 1,800 Rp 210 Rp 378,000
42 Miconazole cream 2% Tube 10 gram PT. Kima Farma 170 Rp 3,000 Rp 510,000
43 Ofloxacin tab 400 mg Box, 5 strip @ 10 tablet PT. Novell Pharmaeutical 1,400 Rp 680 Rp 952,000
44 Oxitosine inj 10 Iu/ml Dus, 10 ampul @ 1 ml PT. Tungal Idaman Abdi 740 Rp 1,900 Rp 1,406,000
45 Pirantel suspensi 125 mg/5 ml Botol 60 ml PT. Holi Pharma 1,100 Rp 8,728 Rp 9,600,800
46 Pirantel tab 125 mg Dus, 25 blister @ 4 tablet PT. Holi Pharma 1,200 Rp 308 Rp 369,600
47 Paracetamol drop 100 mg/ml Dus, 15 botol PT. Indofarma 900 Rp 5,460 Rp 4,914,000
48 Propanolol tab 40 mg Dus, 10 strip @ 10 tab PT. Holi Pharma 1,600 Rp 110 Rp 176,000
49 Paracetamol tab500 mg Dus, 10strip @10 tablert PT. Promedrahardjo Farmasi 15,000 Rp 84 Rp 1,260,000
50 Sianokobalamin (vit 12 ) 500 mcg inj 100 ampul @ 1 ml PT. Lucas Djaja 550 Rp 1,132 Rp 622,600
51 Salbutamol aerosol 100mg Dus, botol 200 dosis PT. Glaxo Wellcome Indonesia 30 Rp 66,938 Rp 2,008,140
52 Salbutamol tab 4mg Ktk 10x10 tablet PT. Kima Farma 2,700 Rp 89 Rp 240,300
53 Setrizin sirup 5mg/ml Botol @ 60 ml PT.Indofarma 290 Rp 8,399 Rp 2,435,710
54 Setrizin tablet 10 mg Box, 10 strips @ 10 capsules PT. Pertiwi Agung 1,130 Rp 186 Rp 210,180
55 Spironolakton tab 25 mg Dus, 10strip @10kaplet S PT. Dexa Medika 1,040 Rp 320 Rp 332,800
56 Vaksin rabies ( verorab ) Dus, 1vial serbuk+1amp@1 PT. Novartis Indonesia 64 Rp 78,500 Rp 5,024,000
57 Valsartarn 80 mg Dus, 3 alu-alu strip@10 tablet PT. Novartis Indonesia 550 Rp 3,900 Rp 2,145,000
58 Zinc Dispersibel 20 mg tab Dus, 10 strip @ 10 tab PT. Indofarma 600 Rp 497 Rp 298,200

BMHP lainnya

59 Povidon lodida lar 10 % 60 ml Botol 60 ml PT. Jaya Medika Industri 490 Rp 6,298 Rp 3,086,020
60 Alkohol 70 % 1 liter btl @ 100 ml PT. Novapharin 20 Rp 27,305 Rp 546,100
Catgut chromic 3/0 + Jarum 1/2 GT 35
61 Box/24 PT. Jaya Medika Industri 144 Rp 7,091 Rp 1,021,104
mm
Catgut plain 3/0 +jarum 1/2 GT 35
62 Box/24 PT. Jaya Medika Industri 144 Rp 7,091 Rp 1,021,104
mm
63 Silk 2/0 + jarum 1/2 GT 35 mm Box/36 PT. Jaya Medika Industri 216 Rp 3,881 Rp 838,296
64 Silk 3/0 + jarum 1/2 GT 35 mm Box/36 PT. Jaya Medika Industri 216 Rp 3,881 Rp 838,296
Safeglove sirgical steril pre powder
65 Psg, (Box = 50 psg) PT. Jaya Medika Industri 300 Rp 88 Rp 26,400
no.7.5
66 Surgical mask 3 fly earloop Box/50 PT. Jaya Medika Industri 300 Rp 419 Rp 125,700
67 Stera syringe 3 cc x 23G x 1 ." Box/100 PT. Jaya Medika Industri 1,200 Rp 826 Rp 991,200
68 Stera syringe 5 cc x 22G x 1 ." Box/100 PT. Jaya Medika Industri 600 Rp 953 Rp 571,800
69 Kasa Hydrophil Steril uk 18 x 22 cm Roll PT. Jaya Medika Industri 101 Rp 7,493 Rp 756,793
Sub Total Rp 80,356,279

Demikian kami sampaikan atas perhatianya kami sampaikan Terima Kasih

Balige, 21 Juni 2015

Diketahui Bendahara Dana Kapitasi JKN

Kepala FKTP UPT Puskesmas Tandang Buhit FKTP UPT Puskesmas Tandang Buhit
Kecamatan Balige Kecamatan Balige

dr. Chandra Siagian Janti Soia Bakara

NIP. 19780304 200604 1 008 NIP. 19710821 199203 2 002