Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 1

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

1 T0004 ACITRAL TABLET TABLET 300 117 500 100 5 59.662,50 298
2 I2629 ACTABONE INJEKSI 300 MG/ 5 ML VIAL 53 12 29 1 29 109.087,50 3.163
3 IA000000003 ACTOPLATIN INJEKSI 150 MG/15 ML AMPUL 0 7 42 1 42 172.725,00 7.254
4 Z0320 ACUATIM KRIM 10 GRAM TUBE 0 3 20 1 20 86.130,00 1.722
5 T0008 ADALAT OROS TABLET 30 MG TABLET 9.060 1.920 3.990 30 133 95.460,68 12.696
6 I0004 ADONA (AC-17) INJEKSI 50 MG/10 ML AMPUL 0 2 10 10 1 208.000,00 208
7 T0011 AERIUS FC TABLET 5 MG TABLET 0 28 180 30 6 198.549,00 1.191
8 I0424 AERRANE INJEKSI 250 ML BOTOL 3 2 11 1 11 1.398.600,00 15.384
9 I0423 ALBAPURE INJEKSI 20 % 100 ML BOTOL 35 30 169 1 169 681.800,00 115.224
10 Z0002 ALBOTHYL LARUTAN 10 ML BOTOL 0 1 5 1 5 26.600,00 133
11 I0891 ALBUMINAR INJEKSI 25 % 100 ML BOTOL 0 39 265 1 265 1.332.000,00 352.980
12 I0006 ALINAMIN F INJEKSI 25 MG/10 ML AMPUL 455 125 395 5 79 47.639,90 3.763
13 Z0285 ALKOHOL 70% 100 ML BOTOL 345 67 111 1 111 2.272,72 252
14 I0900 AMINOFLUID INFUS 500 ML BAG 109 221 1.394 1 1.394 56.000,00 78.064
15 I0012 AMINOFUSIN PAED INFUS 250 ML BOTOL 85 14 10 1 10 41.818,00 418
16 I0014 AMINOLEBAN INFUS BAG 85 15 17 1 17 59.091,00 1.004
17 I0019 AMINOSTERIL INFANT 6% INFUS BOTOL 150 51 197 1 197 33.334,00 6.566
18 I0023 AMOXSAN INJEKSI 1 GRAM VIAL 0 1 10 10 1 202.050,00 202
19 T0034 ANALSIK TABLET TABLET 0 1.517 10.300 100 103 109.000,00 11.227
20 I2636 ANBACIM INJEKSI 1 GRAM VIAL 25 13 63 1 63 67.610,00 4.259
21 T0848 ANBACIM KAPLET KAPLET 0 20 140 20 7 371.200,00 2.598
22 T1465 ANEMOLAT TABLET 1 MG TABLET 3.300 8.583 55.100 100 551 14.840,00 8.176
23 I0028 ANTRAIN INJEKSI 500 MG/ML, AMP @ 2 ML AMPUL 420 219 1.070 5 214 28.595,00 6.119
24 S0224 APIALYS DROP 10 ML BOTOL 0 1 7 1 7 28.500,00 199
25 S0225 APIALYS SYRUP 100 ML BOTOL 0 4 27 1 27 23.750,00 641
26 TA000000023 ARIMIDEX TABLET TABLET 1.680 933 4.676 28 167 814.457,55 136.014
27 I0583 ARIXTRA INJEKSI 2,5MG/0,5ML VIAL 182 55 192 2 96 439.395,00 42.181
Halaman 1 dari 19

HARGA
P)
1

298.312,50
3.163.537,50
7.254.450,00
1.722.600,00
12.696.270,44
208.000,00
1.191.294,00
15.384.600,00
115.224.200,00
133.000,00
352.980.000,00
3.763.552,10
252.271,92
78.064.000,00
418.180,00
1.004.547,00
6.566.798,00
202.050,00
11.227.000,00
4.259.430,00
2.598.400,00
8.176.840,00
6.119.330,00
199.500,00
641.250,00
136.014.410,85
42.181.920,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 2

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

28 I0031 ASERING INFUS FLABOT 2.000 385 618 1 618 8.182,00 5.056
29 T0057 ASPAR K TABLET TABLET 0 42 300 100 3 204.360,00 613
30 T0945 ASPILET THROMBO TABLET TABLET 450 475 2.850 150 19 86.400,00 1.641
31 T0058 ASPILET TABLET TABLET 0 3.350 22.800 100 228 14.500,00 3.306
32 Z0022 ASTHENOF TETES MATA BOTOL 5 1 1 1 1 21.000,00 21
33 T0005 ASTHIN FORCE TABLET TABLET 1.998 737 3.006 18 167 114.075,00 19.050
34 Z0006 ATROVENT INH SOL 20 ML BOTOL 88 17 28 1 28 81.818,18 2.290
35 Z0188 AUGENTONIC TETES MATA 5 ML BOTOL 0 2 14 1 14 25.125,00 351
36 S0198 AVAMYS 120 SPRAY BOTOL 0 1 6 1 6 84.848,20 509
37 I0959 AVASTIN INJEKSI 100 MG VIAL 20 14 75 1 75 4.366.997,27 327.524
38 T0914 AVELOX TABLET 400 MG TABLET 0 2 10 5 2 254.678,00 509
39 T6289 AVODART KAPSUL KAPLET 660 233 930 30 31 193.636,36 6.002
40 Z0008 BACTODERM 5 G KRIM TUBE 0 11 75 1 75 41.000,00 3.075
41 Z0009 BACTROBAN 5 G KRIM TUBE 0 1 5 1 5 35.000,00 175
42 T0089 BD-GARD TABLET TABLET 900 570 2.970 30 99 250.000,00 24.750
43 Z0014 BEROTEC INHALATION SOL 50 ML BOTOL 20 9 41 1 41 106.818,18 4.379
44 Z0176 BEROTEC MDI 100 10 ML BOTOL 29 24 134 1 134 66.272,73 8.880
45 OA000000001 BETADINE OBAT KUMUR 175 ML BOTOL 0 21 143 1 143 16.000,00 2.288
46 I0039 BIOCEF INJEKSI VIAL 0 2 12 1 12 125.000,00 1.500
47 T1378 BIOCURKEM KAPLET TABLET 0 400 2.730 30 91 292.500,00 26.617
48 T1420 BIOCURLIV KAPLET KAPLET 120 85 450 30 15 190.125,00 2.851
49 Z0018 BIOPLACENTON JELLY 15 GRAM TUBE 6 4 21 1 21 12.000,00 252
50 S0015 BISOLVON ELIXIR 60 ML BOTOL 0 1 7 1 7 22.040,00 154
51 I0042 BISOLVON INJEKSI AMPUL 0 52 350 10 35 399.475,00 13.981
52 Z0071 BLECIDEX EYE / EAR DROP BOTOL 0 2 14 1 14 37.015,00 518
53 T0827 BLESIFEN TABLET TABLET 100 67 360 20 18 221.700,00 3.990
54 T1078 BLOPRESS TABLET 16 MG TABLET 0 6 28 14 2 199.760,00 399
Halaman 2 dari 19

HARGA
P)
1

5.056.476,00
613.080,00
1.641.600,00
3.306.000,00
21.000,00
19.050.525,00
2.290.909,04
351.750,00
509.089,20
327.524.795,25
509.356,00
6.002.727,16
3.075.000,00
175.000,00
24.750.000,00
4.379.545,38
8.880.545,82
2.288.000,00
1.500.000,00
26.617.500,00
2.851.875,00
252.000,00
154.280,00
13.981.625,00
518.210,00
3.990.600,00
399.520,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 3

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

55 T1011 BLOPRESS TABLET 8 MG TABLET 0 4 28 14 2 151.780,00 303

56 I0881 BONEFOS INJEKSI AMPUL 15 13 75 5 15 567.977,33 8.519
57 SA000000003 BRAINACT 5 SACHET @ 2GR SACCHET 0 3 15 5 3 82.000,00 246
58 T0093 BRAXIDIN TABLET TABLET 400 358 2.000 100 20 79.000,00 1.580
59 I0883 BREXEL INJEKSI 20 MG VIAL 60 25 110 1 110 800.000,00 88.000
60 I0884 BREXEL INJEKSI 80 MG VIAL 61 27 123 1 123 2.900.000,00 356.700
61 T0760 BRICASMA TABLET TABLET 200 133 700 100 7 205.048,00 1.435
62 I0046 BRICASMA INJEKSI AMPUL 0 2 15 5 3 85.188,40 255
63 T0094 BRM TABLET KAPSUL 120 50 240 60 4 418.181,82 1.672
64 I0048 BROADCED INJEKSI 1 GRAM VIAL 0 231 1.571 1 1.571 145.000,00 227.795
65 Z0314 BURNAZIN KRIM 35 GRAM TUBE 0 1 7 1 7 20.909,00 146
66 T0097 BUSCOPAN TABLET TABLET 0 58 400 100 4 198.720,00 794
67 SA000000001 CALNIC PLUS SUSPENSI BOTOL 0 4 27 1 27 47.500,00 1.282
68 S0293 CALNIC SUSPENSI BOTOL 0 1 7 1 7 42.500,00 297
69 Z0066 CARMED 10% 40 GRAM TUBE 0 1 5 1 5 22.705,00 113
70 Z0031 CARPIN 2% 5ML TETES MATA BOTOL 17 7 31 1 31 19.000,00 589
71 TA000000035 CASODEX TABLET 50 MG TABLET 1.120 245 560 28 20 1.145.323,83 22.906
72 T0107 CATAFLAM TABLET 25 MG TABLET 0 29 200 50 4 118.763,00 475
73 T0108 CATAFLAM TABLET 50 MG TABLET 0 33 200 50 4 226.657,00 906
74 Z0091 CATARLENT 15 ML TETESMATA BOTOL 0 9 61 1 61 30.625,00 1.868
75 I0056 CEFAZOL INJEKSI 1 GRAM VIAL 0 1 5 1 5 85.000,00 425
76 T0118 CEFSPAN KAPSUL 100 MG KAPSUL 0 18 120 30 4 570.000,00 2.280
77 T0119 CELEBREX KAPSUL 100 MG TABLET 0 28 180 30 6 210.853,00 1.265
78 T0120 CELEBREX KAPSUL 200 MG TABLET 0 40 270 30 9 364.188,00 3.277
79 T1310 CELLCEPT KAPSUL 500 MG KAPSUL 1.200 229 350 50 7 727.272,73 5.090
80 Z0034 CENFRESH MINIDOSE STRIP 10 2 2 1 2 23.000,00 46
81 I0801 CEREMAX IV 50 ML +PE TUBING BOTOL 0 5 34 1 34 265.000,00 9.010
Halaman 3 dari 19

HARGA
P)
1

303.560,00
8.519.659,95
246.000,00
1.580.000,00
88.000.000,00
356.700.000,00
1.435.336,00
255.565,20
1.672.727,28
227.795.000,00
146.363,00
794.880,00
1.282.500,00
297.500,00
113.525,00
589.000,00
22.906.476,60
475.052,00
906.628,00
1.868.125,00
425.000,00
2.280.000,00
1.265.118,00
3.277.692,00
5.090.909,11
46.000,00
9.010.000,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 4

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

82 I0069 CERNEVIT INJEKSI VIAL 573 133 331 1 331 144.000,00 47.664
83 I0070 CEROPID INJEKSI 1 GRAM VIAL 20 15 82 2 41 255.000,00 10.455
84 T2242 CESTER CAPSUL TABLET 0 10 60 30 2 71.250,00 142
85 IA000000058 CETROTIDE INJEKSI 0,25 MG VIAL 0 1 7 7 1 3.611.000,00 3.611
86 I0437 CHLORAMEX INJEKSI 1000 MG VIAL 0 3 16 1 16 28.000,00 448
87 Z0059 CHLORETHYL SPRAY 100 ML BOTOL 10 4 17 1 17 109.250,00 1.857
88 Z0235 CIDEX OPA 5 LITER BOTOL 0 2 14 1 14 665.500,00 9.317
89 T1369 CIPRALEX TABLET 10 MG TABLET 0 5 28 28 1 475.000,00 475
90 I0080 CLINIMIX N9G15E INFUS 1 LITER BAG 47 36 198 1 198 180.909,09 35.819
91 T6323 CODIPRONT CUM EXPECT TABLET 0 60 410 10 41 86.800,00 3.558
92 T1475 CODIPRONT KAPSUL KAPSUL 0 83 600 100 6 656.000,00 3.936
93 I0549 COMAFUSIN HEPAR INFUS 500 ML BOTOL 70 18 52 1 52 59.000,00 3.068
94 Z0516 COMBIVENT NEBULES AMPUL 40 42 240 20 12 108.909,09 1.306
95 T0151 COMTRO TABLET 250 MG TABLET 0 15 100 20 5 163.350,00 816
96 S0024 COMTUSI SIRUP BOTOL 0 1 7 1 7 32.455,00 227
97 T0153 CONCOR TABLET 2.5 MG TABLET 0 3.075 20.900 100 209 67.818,15 14.173
98 I0084 CORDARON INJEKSI AMPUL 108 43 186 6 31 68.073,00 2.110
99 I0905 CRAVIT INFUS 750 MG BOTOL 10 19 119 1 119 268.180,00 31.913
100 Z0063 CRAVIT TETES MATA BOTOL 0 1 7 1 7 110.000,00 770
101 I0580 CRAVOX INFUS BOTOL 0 5 30 1 30 190.000,00 5.700
102 I0089 CURACIL INJEKSI 500 MG VIAL 767 201 600 1 600 30.000,00 18.000
103 T0162 CURCUMA TABLET TABLET 2.200 3.333 20.500 100 205 66.000,00 13.530
104 T1514 CYCLO PROGYNOVA TABLET TABLET 0 18 84 21 4 107.800,00 431
105 IA000000034 CYCLOVID INJEKSI 1 GRAM VIAL 12 3 6 1 6 232.727,27 1.396
106 Z0186 CYGEST OVULA 400 MG OVULA 150 56 225 15 15 300.000,00 4.500
107 I0888 CYMEVENE INJEKSI 500 MG VIAL 15 3 5 1 5 363.181,82 1.815
108 T5678 CYTODROX TABLET 500 MG TABLET 0 492 3.300 100 33 568.167,60 18.749
Halaman 4 dari 19

HARGA
P)
1

47.664.000,00
10.455.000,00
142.500,00
3.611.000,00
448.000,00
1.857.250,00
9.317.000,00
475.000,00
35.819.999,82
3.558.800,00
3.936.000,00
3.068.000,00
1.306.909,08
816.750,00
227.185,00
14.173.993,35
2.110.263,00
31.913.420,00
770.000,00
5.700.000,00
18.000.000,00
13.530.000,00
431.200,00
1.396.363,62
4.500.000,00
1.815.909,10
18.749.530,80
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 5

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

109 I0919 DACTICIN INJEKSI 0,5 MG VIAL 0 7 48 1 48 1.572.231,82 75.467

110 T0169 DANOCRINE TABLET 200 MG TABLET 0 67 500 100 5 944.047,00 4.720
111 T0171 DANSERA TABLET TABLET 0 158 1.100 100 11 500.000,00 5.500
112 Z0069 DARYANTULLE STERIL GAUZE LEMBAR 1.050 503 2.370 10 237 87.875,00 20.826
113 T0173 DEGRIUM TABLET 5 MG TABLET 400 146 600 50 12 252.000,00 3.024
114 S0108 DEPAKENE SIRUP 250 MG / 5 ML 120 ML BOTOL 8 2 4 1 4 67.095,24 268
115 T1395 DEPAKOTE ER TABLET 250 MG TABLET 0 200 1.400 100 14 253.909,00 3.554
116 TA000000054 DEPAKOTE ER TABLET 500 MG TABLET 400 83 100 100 1 495.455,00 495
117 T0175 DEPAKOTE TABLET 250 MG TABLET 800 833 4.900 100 49 152.727,00 7.483
118 I0665 DESFERAL INJEKSI 500 MG / ML INJEKSI 0 2 10 10 1 1.018.182,00 1.018
119 Z0077 DESOLEX 10 GRAM CREM TUBE 0 1 6 1 6 17.817,25 106
120 T0182 DIAMICRON MR TABLET 30 MG TABLET 1.440 225 120 60 2 34.800,00 69
121 TA000000055 DIANE 35 TABLET TABLET 0 9 42 21 2 88.800,00 177
122 I0224 DICYNON INJEKSI 250 MG AMPUL 0 13 90 6 15 188.100,00 2.821
123 T0189 DIOVAN TABLET 80 MG TABLET 7.740 3.798 18.090 30 603 106.363,63 64.137
124 T0780 DIOVAN TABLET 160 MG TABLET 6.810 1.060 390 30 13 177.272,73 2.304
125 T0714 DIVEN PLUS KAPSUL KAPSUL 0 10 60 60 1 165.000,00 165
126 T1414 DOPAMET TABLET TABLET 0 83 600 100 6 72.726,00 436
127 T1480 DORNER TABLET 20 MCG TABLET 2.310 975 4.320 30 144 98.182,00 14.138
128 T1279 DROVAX KAPSUL 500 MG KAPSUL 0 5 30 30 1 75.000,00 75
129 Z0080 DULCOLAX SUPP. ADULT SUPPOS 0 117 800 50 16 506.596,00 8.105
130 T0195 DULCOLAX TABLET TABLET 0 117 800 200 4 168.480,00 673
131 Z0185 DUMIN RECTAL 125 MG VIAL 2 1 5 5 1 53.000,00 53
132 T6279 DUPHASTON TABLET 10 MG TABLET 0 45 300 20 15 263.435,00 3.951
133 N0032 DUROGESIC MATRIX 25 MU LEMBAR 45 33 180 5 36 695.455,00 25.036
134 I0544 DYNASTAT INJEKSI 40 MG VIAL 0 63 428 1 428 103.725,00 44.394
135 I0117 EAS INFUS BOTOL 300 217 1.176 1 1.176 46.600,00 54.801
Halaman 5 dari 19

HARGA
P)
1

75.467.127,36
4.720.235,00
5.500.000,00
20.826.375,00
3.024.000,00
268.380,96
3.554.726,00
495.455,00
7.483.623,00
1.018.182,00
106.903,50
69.600,00
177.600,00
2.821.500,00
64.137.268,89
2.304.545,49
165.000,00
436.356,00
14.138.208,00
75.000,00
8.105.536,00
673.920,00
53.000,00
3.951.525,00
25.036.380,00
44.394.300,00
54.801.600,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 6

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

136 I0724 ECRON INJEKSI 10 MG VIAL 0 19 129 1 129 137.700,00 17.763

137 Z0081 EFRICEL 10% TETES MATA BOTOL 1 1 5 1 5 15.250,00 76
138 S0037 ELKANA SIRUP 60 ML BOTOL 1 3 19 1 19 18.860,00 358
139 IA000000020 ELOXATIN INJEKSI 100 MG / 20 ML VIAL 51 9 10 1 10 1.000.000,00 10.000
140 Z0289 EMLA 5% CREAM 5 G TUBE 12 2 2 1 2 45.194,40 90
141 IA000000032 ENDOXAN INJEKSI 1000 MG VIAL 11 10 57 1 57 232.678,44 13.262
142 I0965 ENDROLIN INJEKSI 3.75 MG VIAL 0 2 14 1 14 945.000,00 13.230
143 S0204 ENERCORE SACHET SACCHET 0 7 50 5 10 87.750,00 877
144 I0841 EPREX INJEKSI 2000 IU VIAL 66 16 43 1 43 121.692,38 5.232
145 IA000000044 ERBITUX INJEKSI 5 MG / 20 ML (REGULER) VIAL 130 31 81 1 81 3.318.181,82 268.772
146 T1491 ESCOVIT TABLET TABLET 0 67 500 100 5 657.000,00 3.285
147 IA000000054 ETHIGENT INJEKSI 80 MG/2 ML AMPUL 0 4 20 5 4 14.486,00 57
148 I2650 ETOPUL INJEKSI AMPUL 0 12 80 5 16 455.000,00 7.280
149 T0218 EUTHYROX TABLET 100MG TABLET 2.000 1.392 7.500 100 75 77.272,73 5.795
150 T2245 EXJADE TABLET 250 MG KAPSUL 1.316 399 1.400 28 50 1.934.545,43 96.727
151 I0132 EXTRACE INJEKSI AMPUL 0 1 6 6 1 39.000,00 39
152 Z0505 FAKTU SUPPOSITORIA SUPPOS 20 5 10 10 1 67.500,00 67
153 I0748 FARGOXIN INJEKSI VIAL 66 11 10 5 2 99.995,00 199
154 IA000000050 FARSORBID INJEKSI AMPUL 42 19 88 2 44 60.000,00 2.640
155 T1363 FEROGLOBIN KAPSUL KAPSUL 0 5 30 30 1 55.000,00 55
156 T1421 FERRIPROX TABLET 500 MG TABLET 3.900 1.017 3.000 100 30 2.299.960,00 68.998
157 Z0502 FITAJOINT GEL 35 GRAM TUBE 0 2 14 1 14 65.700,00 919
158 T1325 FITBON TABLET 500 MG TABLET 0 770 5.220 60 87 61.861,80 5.381
159 I0142 FLAGYL INFUS BAG 20 4 4 1 4 72.917,00 291
160 I0602 FLAMICORT INJEKSI 10 MG / ML IA / ID VIAL 8 4 19 1 19 59.545,43 1.131
161 Z0221 FLEET ENEMA BOTOL 141 61 274 1 274 56.826,00 15.570
162 Z0215 FLIXOTIDE NEBULIZER VIAL 0 21 140 10 14 117.427,00 1.643
Halaman 6 dari 19

HARGA
P)
1

17.763.300,00
76.250,00
358.340,00
10.000.000,00
90.388,80
13.262.671,08
13.230.000,00
877.500,00
5.232.772,34
268.772.727,42
3.285.000,00
57.944,00
7.280.000,00
5.795.454,75
96.727.271,50
39.000,00
67.500,00
199.990,00
2.640.000,00
55.000,00
68.998.800,00
919.800,00
5.381.976,60
291.668,00
1.131.363,17
15.570.324,00
1.643.978,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 7

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

163 Z0038 FLOXA MINI DOSE STRIP 0 4 27 1 27 26.750,00 722

164 T0243 FOLAMIL TABLET TABLET 0 42 300 100 3 105.000,00 315
165 T1308 FOLAVIT TABLET 400 MCG TABLET 200 142 800 100 8 70.000,00 560
166 T0248 FORNEURO TABLET TABLET 0 105 720 30 24 136.000,00 3.264
167 I0780 FORTANEST INJEKSI 5 MG/5ML AMPUL 868 168 275 5 55 25.454,55 1.400
168 T6337 FORTIBI TABLET TABLET 0 3 30 30 1 87.750,00 87
169 I0091 FOSMIDEX INJEKSI 1 GRAM VIAL 0 11 80 10 8 765.000,00 6.120
170 T1314 FUCOIDAN KAPSUL 100 MG KAPSUL 0 54 360 18 20 184.275,00 3.685
171 Z0094 FUSYCOM KRIM 5 GRAM TUBE 0 23 156 1 156 24.000,00 3.744
172 IA000000010 FUTROLIT INFUS BOTOL 16 16 93 1 93 32.500,00 3.022
173 T6326 GABEXAL KAPSUL 100 MG TABLET 0 508 3.450 30 115 65.455,00 7.527
174 T1385 GABEXAL KAPSUL 300 MG TABLET 0 210 1.440 30 48 79.118,40 3.797
175 I0556 GAMARAS INJEKSI BOTOL 0 2 10 1 10 2.565.000,00 25.650
176 T1352 GASTRUL TABLET TABLET 0 8 60 30 2 279.300,00 558
177 I0864 GEMZAR INJEKSI 200 MG VIAL 0 2 12 1 12 299.994,47 3.599
178 Z0527 GENOINT SALEP MATA TUBE 0 71 483 1 483 2.364,00 1.141
179 Z0231 GENTASOLON KRIM 10 GRAM TUBE 0 1 7 1 7 23.000,00 161
180 Z0098 GENTASOLON KRIM 5 GRAM TUBE 0 3 20 1 20 16.000,00 320
181 Z0229 GIGASEPT /LYSETOL SOL BOTOL 13 5 21 1 21 1.249.110,00 26.231
182 T0261 GLAUCON TABLET TABLET 0 642 4.400 100 44 163.636,36 7.199
183 T1025 GLUCODEX TABLET TABLET 1.400 692 3.300 100 33 28.173,48 929
184 I2623 GLUTIVEN INFUS 100 ML BOTOL 0 2 14 1 14 414.000,00 5.796
185 T1444 GLUTROP KAPLET KAPLET 900 303 1.170 30 39 374.300,00 14.597
186 T1028 GOFLEX TABLET TABLET 1.080 303 990 30 33 219.450,00 7.241
187 T0276 HARNAL TABLET 0.2 MG TABLET 2.520 394 168 28 6 147.636,00 885
188 I0170 HEMAPO INJEKSI 3000 IU / ML VIAL 315 84 256 1 256 116.364,00 29.789
189 T0278 HEMOBION KAPSUL KAPSUL 0 83 600 100 6 118.681,20 712
Halaman 7 dari 19

HARGA
P)
1

722.250,00
315.000,00
560.000,00
3.264.000,00
1.400.000,25
87.750,00
6.120.000,00
3.685.500,00
3.744.000,00
3.022.500,00
7.527.325,00
3.797.683,20
25.650.000,00
558.600,00
3.599.933,64
1.141.812,00
161.000,00
320.000,00
26.231.310,00
7.199.999,84
929.724,84
5.796.000,00
14.597.700,00
7.241.850,00
885.816,00
29.789.184,00
712.087,20
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 8

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

190 T6340 HEPA BALANCE TABLET KAPSUL 0 30 180 60 3 594.000,00 1.782

191 I0820 HEPAMERZ INJEKSI AMPUL 0 4 25 5 5 496.374,67 2.481
192 TA000000036 HEPSERA TABLET 10 MG TABLET 0 20 120 30 4 750.000,00 3.000
193 T1256 HERBESSER CD 100 TABLET TABLET 3.210 870 2.700 30 90 100.009,09 9.000
194 T0734 HERBESSER CD 200 TABLET TABLET 6.840 1.845 5.700 30 190 109.500,00 20.805
195 IA000000031 HERCEPTIN INJEKSI 440 MG VIAL 28 7 20 1 20 17.825.485,45 356.509
196 IA000000052 HERCEPTIN INJEKSI 440 MG (FREE) BUAH 15 7 33 1 33 0,00
197 T1404 HERCLOV TABLET TABLET 0 13 100 50 2 655.750,00 1.311
198 T0282 HEXYMER TABLET 2 MG TABLET 0 2.646 18.000 250 72 80.000,00 5.760
199 I0511 HIDONAC INFUS 200 MG / ML VIAL 2 13 86 1 86 302.100,00 25.980
200 I0934 HIPERHEP INJEKSI VIAL 1 1 5 1 5 1.207.273,00 6.036
201 T0813 HITROL KAPSUL KAPSUL 0 53 360 30 12 156.487,50 1.877
202 I0825 HOLOXAN INJEKSI 2000 MG VIAL 44 14 51 1 51 2.597.684,86 132.481
203 T0285 HP PRO TABLET KAPSUL 360 940 6.000 120 50 536.363,64 26.818
204 I2606 HUMALOG CART 100 IU / ML AMPUL 0 20 135 5 27 359.850,00 9.715
205 IA000000029 HUMALOG MIX CART 100 IU / ML AMPUL 345 68 115 5 23 443.181,82 10.193
206 Z0324 HYDREX 5 LITER GALON 2 1 5 1 5 760.145,00 3.800
207 I0752 HYPOBAC INJEKSI 100MG VIAL 116 39 149 1 149 131.098,00 19.533
208 I0181 HYPOBAC INJEKSI 200 MG VIAL 10 31 201 1 201 233.633,00 46.960
209 Z0284 IFLACORT SALEP KULIT 10 GRAM TUBE 0 2 14 1 14 55.822,00 781
210 Z0239 IKAMICETIN SALEP KULIT TUBE 0 13 88 1 88 6.500,00 572
211 T0293 IMBOOST FORCE TABLET TABLET 0 202 1.380 30 46 160.875,00 7.400
212 S0045 IMUNOS SIRUP BOTOL 0 1 7 1 7 49.875,00 349
213 T0296 IMUNOS TABLET TABLET 580 332 1.680 20 84 104.500,00 8.778
214 T0297 INAMID TABLET TABLET 200 58 200 100 2 19.090,91 38
215 Z0106 INERSON SALF 15 G TUBE 0 15 102 1 102 13.637,63 1.391
216 T0310 INTERHISTIN TABLET TABLET 0 200 1.400 100 14 54.625,00 764
Halaman 8 dari 19

HARGA
P)
1

1.782.000,00
2.481.873,35
3.000.000,00
9.000.818,10
20.805.000,00
356.509.709,00
0,00
1.311.500,00
5.760.000,00
25.980.600,00
6.036.365,00
1.877.850,00
132.481.927,86
26.818.182,00
9.715.950,00
10.193.181,86
3.800.725,00
19.533.602,00
46.960.233,00
781.508,00
572.000,00
7.400.250,00
349.125,00
8.778.000,00
38.181,82
1.391.038,26
764.750,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 9

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

217 T0820 INTUNAL FORTE TABLET TABLET 0 83 600 100 6 62.700,00 376
218 I0223 INVICLOT INJEKSI 5000 IU / ML VIAL 516 198 830 1 830 39.000,00 32.370
219 IA000000042 IOPAMIRO INJEKSI 300 MG 100 ML VIAL 10 8 44 1 44 318.182,00 14.000
220 I0191 IOPAMIRO INJEKSI 300 MG 50 ML VIAL 218 113 550 1 550 150.909,00 82.999
221 I2664 IOPAMIRO INJEKSI 370 MG 100 ML BOTOL 4 1 3 1 3 335.455,00 1.006
222 I2670 IOPAMIRO INJEKSI 370 MG 50 ML VIAL 2 1 5 1 5 180.909,09 904
223 TA000000019 IRESSA TABLET 250 MG TABLET 680 242 970 10 97 2.681.397,60 260.095
224 I0443 KABIVEN PERIPHERAL INJEKSI 1440 ML BAG 64 17 52 1 52 268.400,00 13.956
225 I0199 KAEN 3A FLABOT 0 8 54 1 54 9.091,00 490
226 S0048 KALITAKE SACCHET 40 60 360 20 18 140.005,35 2.520
227 T0328 KALNEX TABLET 500 MG TABLET 0 258 1.800 100 18 260.000,00 4.680
228 Z0114 KALTROFEN SUPPOSITORIA 100 MG SUPPOS 0 3 20 10 2 110.000,00 220
229 T0329 KALTROFEN TABLET 50 MG TABLET 0 15 90 30 3 75.000,00 225
230 T0333 KALXETIN TABLET 20 MG TABLET 0 33 210 30 7 156.000,00 1.092
231 S0177 KANDISTATIN SUSP. 100.000 IU/ML, BTL 12 ML BOTOL 31 25 139 1 139 28.000,00 3.892
232 Z0297 KENALOG IN ORABASE 5GR TUBE 0 4 27 1 27 44.600,00 1.204
233 I0058 KETESE INJEKSI AMPUL 35 277 1.850 5 370 235.000,00 86.950
234 T0823 KETESE TABLET TABLET 0 50 350 50 7 379.480,00 2.656
235 Z0194 KETOMED KRIM 15 GRAM TUBE 4 1 2 1 2 19.665,00 39
236 Z0240 KETOMED SHAMPOO 60 ML BOTOL 0 3 20 1 20 30.043,75 600
237 T0337 KETOSTERIL TABLET TABLET 600 458 2.500 100 25 552.000,00 13.800
238 I0214 KIDMIN 7.2% 200 ML BOTOL 874 314 1.261 1 1.261 41.818,00 52.732
239 Z0146 KLODERMA KRIM 10 GRAM TUBE 0 4 27 1 27 23.750,00 641
240 Z0119 KLODERMA KRIM 5 GRAM TUBE 6 2 8 1 8 15.960,00 127
241 Z0224 KLODERMA OINT 10 GRAM TUBE 0 4 27 1 27 23.750,00 641
242 I0805 KOATE INJEKSI 480 IU - 600 IU BOTOL 346 118 456 1 456 1.954.467,65 891.237
243 T0323 KSR TABLET TABLET 2.300 1.300 6.500 100 65 143.636,37 9.336
Halaman 9 dari 19

HARGA
P)
1

376.200,00
32.370.000,00
14.000.008,00
82.999.950,00
1.006.365,00
904.545,45
260.095.567,20
13.956.800,00
490.914,00
2.520.096,30
4.680.000,00
220.000,00
225.000,00
1.092.000,00
3.892.000,00
1.204.200,00
86.950.000,00
2.656.360,00
39.330,00
600.875,00
13.800.000,00
52.732.498,00
641.250,00
127.680,00
641.250,00
891.237.248,40
9.336.364,05
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 10

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

244 S0052 LACTO B BUNGKUS 120 57 280 40 7 140.250,00 981

245 S0055 LAXADIN SIRUP 60 ML BOTOL 0 27 184 1 184 11.318,00 2.082
246 T0354 LESICHOL TABLET 300 MG TABLET 0 35 240 60 4 480.000,00 1.920
247 I0221 LEUNASE INJEKSI VIAL 20 4 7 1 7 945.000,00 6.615
248 I0662 LEVEMIR INJEKSI PEN 170 78 360 5 72 386.363,63 27.818
249 I0767 LEVOSOL INJEKSI 8 MG AMPUL 20 6 20 5 4 245.000,00 980
250 Z0348 LFX MINIDOSE TETES MATA STRIP 21 11 54 1 54 69.000,00 3.726
251 I0478 LIDODEX INJEKSI 5 % AMPUL 0 1 5 5 1 266.750,00 266
252 I2619 LIPOFUNDIN INFUS 100 ML BOTOL 5 2 7 1 7 95.909,00 671
253 T0868 LIZOR TABLET TABLET 0 27 180 20 9 450.500,00 4.054
254 I0885 LODOMER INJEKSI 5 MG AMPUL 72 15 36 12 3 68.182,00 204
255 Z0125 LOMATUELL LEMBAR 0 23 160 10 16 123.500,00 1.976
256 I0229 LOVENOX INJEKSI 60 MG/0,6 ML VIAL 8 3 12 2 6 181.818,00 1.090
257 T0383 LYSAGOR TABLET TABLET 0 128 870 30 29 26.500,00 768
258 Z0040 LYTEERS 15 ML BOTOL 6 39 259 1 259 22.500,00 5.827
259 I0910 MABTHERA INJEKSI 500 MG VIAL 3 3 17 1 17 14.385.478,18 244.553
260 IA000000053 MABTHERA INJEKSI 500 MG (FREE) BUAH 5 3 15 1 15 0,00
261 I0560 MACEF INJEKSI VIAL 0 3 18 1 18 242.500,00 4.365
262 T0385 MADOPAR KAPS. TABLET 0 158 1.080 30 36 64.090,91 2.307
263 I0908 MAGNESIUM SULFAT INJEKSI 20 % 25 ML VIAL 0 12 82 1 82 2.545,00 208
264 I0235 MARCAIN INJEKSI 0.5 % PDF 20 ML AMPUL 15 10 55 5 11 350.490,00 3.855
265 T0387 MATOVIT TABLET TABLET 0 5 30 30 1 93.600,00 93
266 Z0128 MEDERMA KRIM 20 GRAM TUBE 0 1 6 1 6 143.687,50 862
267 Z0129 MEDIKLIN GEL 15 GRAM TUBE 0 1 7 1 7 17.955,00 125
268 T0789 MEIACT TABLET 200 MG TABLET 0 130 880 20 44 400.000,00 17.600
269 IA000000002 MENOPUR INJEKSI VIAL 0 6 40 10 4 4.230.000,00 16.920
270 TA000000043 MERLOPAM TABLET 2 MG TABLET 200 58 200 100 2 260.000,00 520
alaman 10 dari 19

HARGA
P)
1

981.750,00
2.082.512,00
1.920.000,00
6.615.000,00
27.818.181,36
980.000,00
3.726.000,00
266.750,00
671.363,00
4.054.500,00
204.546,00
1.976.000,00
1.090.908,00
768.500,00
5.827.500,00
244.553.129,06
0,00
4.365.000,00
2.307.272,76
208.690,00
3.855.390,00
93.600,00
862.125,00
125.685,00
17.600.000,00
16.920.000,00
520.000,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:21 Halaman 11

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

271 Z0525 MERTUS CREAM TUBE 0 1 6 1 6 48.593,00 291

272 I0082 METHYCOBAL INJEKSI 500 MIKROGRAM AMPUL 0 13 80 10 8 255.523,00 2.044
273 I0247 MEYLON INJEKSI 8.4 % 25 ML VIAL 480 82 78 1 78 5.636,00 439
274 T6300 MICARDIS 80MG TABLET KAPLET 1.840 555 1.940 20 97 118.181,82 11.463
275 Z0288 MICROLAX ENEMA TUBE 31 15 71 1 71 15.200,00 1.079
276 Z0233 MICROSHILELD 4% 5 LITER GALON 6 2 8 1 8 808.500,00 6.468
277 Z0103 MOFACORT KRIM 10 GRAM TUBE 0 2 14 1 14 52.250,00 731
278 Z0196 MOFACORT KRIM 5 GRAM TUBE 19 5 15 1 15 27.312,50 409
279 N0015 MST TABLET 10 MG TABLET 4.320 740 720 60 12 852.000,00 10.224
280 N0026 MST TABLET 15 MG TABLET 240 75 300 60 5 1.254.000,00 6.270
281 T0430 MUCOHEXIN TABLET TABLET 0 33 200 100 2 41.000,00 82
282 T0860 MUCOSTA TABLET 100 MG TABLET 0 58 394 1 394 3.761,10 1.481
283 I0966 MYCAMINE INJEKSI 50 MG VIAL 0 1 6 1 6 236.364,00 1.418
284 Z0044 MYCOS SALEP MATA TUBE 5 6 36 1 36 26.250,00 945
285 Z0043 MYCOS TETES MATA 5 ML BOTOL 0 5 34 1 34 19.875,00 675
286 Z0042 MYDRIATYL TETES MATA 1 % BOTOL 4 1 3 1 3 38.250,00 114
287 I0835 MYOMERGIN INJEKSI AMPUL 0 48 330 10 33 40.500,00 1.336
288 T0434 MYONAL TABLET 50 MG TABLET 0 125 900 100 9 592.741,00 5.334
289 T1285 MYOVITON TABLET TABLET 0 275 1.900 100 19 180.000,00 3.420
290 I0273 N EPI INJEKSI AMPUL 0 49 335 5 67 382.500,00 25.627
291 YA000000007 NASACORT AQ NASAL SPRAY BOTOL 14 8 40 1 40 81.818,00 3.272
292 I0914 NAVELBINE INJEKSI 10MG VIAL 56 18 66 1 66 1.118.180,00 73.799
293 Z0138 NEBACETIN POWDER BOTOL 0 2 14 1 14 17.575,00 246
294 IA000000039 NEFROFER INJEKSI AMPUL 0 3 15 5 3 363.636,00 1.090
295 I0304 NEO K INJEKSI 2 MG/ML BOX 90 97 570 5 114 49.280,00 5.617
296 I0940 NEOSTIGMIN INJEKSI 0.5 MG AMPUL 220 53 140 5 28 43.181,60 1.209
297 I2602 NEPHROSTERIL 250 ML BOTOL 56 44 243 1 243 46.200,00 11.226
alaman 11 dari 19

HARGA
P)
1

291.558,00
2.044.184,00
439.608,00
11.463.636,54
1.079.200,00
6.468.000,00
731.500,00
409.687,50
10.224.000,00
6.270.000,00
82.000,00
1.481.873,40
1.418.184,00
945.000,00
675.750,00
114.750,00
1.336.500,00
5.334.669,00
3.420.000,00
25.627.500,00
3.272.720,00
73.799.880,00
246.050,00
1.090.908,00
5.617.920,00
1.209.084,80
11.226.600,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:22 Halaman 12

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

298 T0444 NERIPROS 2 MG TABLET TABLET 0 8 60 30 2 199.500,00 399

299 T0865 NERVAPLUS TABLET TABLET 0 58 400 50 8 100.000,00 800
300 T1452 NEULIN PS TABLET TABLET 0 68 450 30 15 315.000,00 4.725
301 I0264 NEUROBION 5000 INJEKSI AMPUL 0 72 500 20 25 130.811,40 3.270
302 T0870 NEUROSANBE 5000 TABLET TABLET 0 25 200 100 2 209.000,00 418
303 T0453 NEUROSANBE TABLET TABLET 0 50 300 100 3 96.500,00 289
304 I0270 NEUROTAM INJEKSI 3 GRAM AMPUL 36 8 12 4 3 208.000,00 624
305 T0462 NEW DIATAB TABLET TABLET 100 458 3.000 100 30 46.200,00 1.386
306 I0473 NEXIUM INJEKSI VIAL 17 42 269 1 269 155.990,00 41.961
307 Z0088 NIACEF GEL 15 GRAM TUBE 0 1 6 1 6 22.467,50 134
308 S0304 NIFLEC POWDER PCS 8 3 12 1 12 152.000,00 1.824
309 T0467 NIMOTOP TABLET TABLET 50 29 150 50 3 322.000,00 966
310 T1284 NITROKAF RETARD TABLET TABLET 24.400 9.467 40.000 100 400 135.727,00 54.290
311 I0561 NOKOBA INJEKSI 0.4 MG/ML AMPUL 5 2 10 5 2 280.000,00 560
312 Z0045 NONCORT MINIDOSE STRIP 0 2 14 1 14 42.250,00 591
313 T0472 NONFLAMIN KAPSUL KAPSUL 0 20 120 60 2 201.883,98 403
314 I0278 NOVALGIN INJEKSI 500 MG/ML AMPUL 0 135 920 5 184 47.419,00 8.725
315 I0778 NOVELLMYCIN INJEKSI 1 GRAM VIAL 0 3 18 1 18 80.000,00 1.440
316 I0953 NOVERON INJEKSI VIAL 0 3 24 12 2 897.600,00 1.795
317 I0848 NOVOMIX 30 FLEXIPEN PEN 1.635 336 650 5 130 481.818,17 62.636
318 IA000000059 NTG INJEKSI 10MG AMPUL 0 5 30 10 3 373.750,00 1.121
319 T1453 NU Q TEN COM TABLET TABLET 90 63 330 30 11 240.000,00 2.640
320 WA000000052 OKSIGEN CAIR - CENTRAL ASTER LITER -5.941.200 0 5.941.000 1.000 5.941 4.350,00 25.843
321 WA000000053 OKSIGEN CAIR - CENTRAL GUDANG LITER -8.049.618 0 8.050.000 1.000 8.050 4.350,00 35.017
322 I0281 OMNIPAQUE INJEKSI 300 MG 50 ML VIAL 0 13 90 10 9 2.070.000,00 18.630
323 I2633 OPIGRAN INJEKSI 1 MG AMPUL 55 45 250 5 50 240.000,00 12.000
324 I2634 OPIGRAN INJEKSI 3 MG AMPUL 315 175 875 5 175 500.000,00 87.500
alaman 12 dari 19

HARGA
P)
1

399.000,00
800.000,00
4.725.000,00
3.270.285,00
418.000,00
289.500,00
624.000,00
1.386.000,00
41.961.310,00
134.805,00
1.824.000,00
966.000,00
54.290.800,00
560.000,00
591.500,00
403.767,96
8.725.096,00
1.440.000,00
1.795.200,00
62.636.362,10
1.121.250,00
2.640.000,00
25.843.350,00
35.017.500,00
18.630.000,00
12.000.000,00
87.500.000,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:22 Halaman 13

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

325 T1359 OSCAL KAPSUL 0,25 MCG KAPSUL 0 75 510 30 17 157.700,00 2.680
326 T0498 OSSORAL 200 TABLET TABLET 0 65 420 60 7 60.000,00 420
327 T0499 OSSORAL 800 TABLET TABLET 0 185 1.260 60 21 234.000,00 4.914
328 T1083 OSTEOCAL TABLET KAPLET 4.104 678 504 72 7 36.591,36 256
329 I0474 OVIDREL INJEKSI 250 MCG VIAL 0 4 27 1 27 579.000,00 15.633
330 Z0145 OXOFERIN SOL BOTOL 0 2 14 1 14 58.500,00 819
331 IA000000048 PACLITAXEL INJEKSI 30 MG/5ML VIAL 0 218 1.482 1 1.482 245.491,17 363.817
332 T1330 PANTOGAR KAPSUL KAPSUL 0 11 45 45 1 219.450,00 219
333 I0954 PANTOPRAZOLE INJEKSI VIAL 0 62 422 1 422 40.000,00 16.880
334 T0508 PANTOZOL TABLET 20MG TABLET 0 25 168 7 24 93.600,00 2.246
335 T0509 PANTOZOL TABLET 40MG TABLET 0 6 42 7 6 118.800,00 712
336 T0505 PARIET TABLET 10 MG TABLET 0 2 14 14 1 205.193,00 205
337 IA000000033 PEGASYS PREFILLED SYRINGE 135 MCG BUAH 33 6 8 1 8 979.831,82 7.838
338 I2655 PEGASYS PREFILLED SYRINGE 180 MCG VIAL 0 5 34 1 34 1.134.745,45 38.581
339 I0291 PEHACAIN INJEKSI 2 % AMPUL 200 105 520 20 26 56.601,00 1.471
340 I0857 PEHAMOXIL INJEKSI 1000 MG VIAL 0 24 163 1 163 10.609,20 1.729
341 I0830 PELASTIN INJEKSI BOTOL 531 125 319 1 319 230.872,20 73.648
342 I0738 PERDIPINE INJEKSI 10 MG AMPUL 80 45 230 10 23 1.118.262,04 25.720
343 T1306 PETRAZOLE KAPSUL TABLET 0 7 48 12 4 176.700,00 706
344 I0971 PHINEV INJEKSI 0.1 % 1 ML VIAL 190 38 70 10 7 70.359,10 492
345 I0485 PICYN INJEKSI 1500 MG VIAL 152 81 399 1 399 121.250,00 48.378
346 I0297 PIRALEN INJEKSI AMPUL 1.590 590 2.420 5 484 18.750,00 9.075
347 Z0526 PIROTOP KRIM 10 GRAM TUBE 0 1 7 1 7 50.326,25 352
348 I0834 PITOGIN INJEKSI AMPUL 80 74 420 10 42 56.250,00 2.362
349 I0299 PLASBUMIN INJEKSI 20% 100 ML BOTOL 0 1 6 1 6 818.182,00 4.909
350 I0487 PLASBUMIN INJEKSI 20% 50 ML BOTOL 0 7 48 1 48 376.363,64 18.065
351 I0298 PLASBUMIN INJEKSI 25% 50 ML BOTOL 77 17 39 1 39 666.115,00 25.978
alaman 13 dari 19

HARGA
P)
1

2.680.900,00
420.000,00
4.914.000,00
256.139,52
15.633.000,00
819.000,00
363.817.913,94
219.450,00
16.880.000,00
2.246.400,00
712.800,00
205.193,00
7.838.654,56
38.581.345,30
1.471.626,00
1.729.299,60
73.648.231,80
25.720.026,92
706.800,00
492.513,70
48.378.750,00
9.075.000,00
352.283,75
2.362.500,00
4.909.092,00
18.065.454,72
25.978.485,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:22 Halaman 14

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

352 I0794 PLASBUMIN INJEKSI 5% 250 ML BOTOL 0 1 6 1 6 818.181,82 4.909

353 I1565 PLASMANAT INJEKSI BOTOL 3 1 4 1 4 883.636,00 3.534
354 T1496 PLASMIN TABLET TABLET 0 9 72 36 2 306.000,00 612
355 T2240 PLETAAL TABLET 100 MG TABLET 0 3 30 30 1 366.600,00 366
356 T0527 PLETAAL TABLET 50 MG TABLET 0 25 200 100 2 659.790,00 1.319
357 Z0046 POLYDEX 0.6 MINIDOSE STRIP 0 4 27 1 27 26.500,00 715
358 T1320 POSTOVIT TABLET TABLET 0 42 300 50 6 135.000,00 810
359 I0597 PRECEDEX INJEKSI VIAL 0 1 5 1 5 462.870,05 2.314
360 I0497 PREGNYL INJEKSI 5000 IU VIAL 0 2 14 1 14 303.770,00 4.252
361 T0897 PRESEPT 2,5 GR TABLET TABLET 1.300 500 2.100 100 21 322.000,00 6.762
362 T0537 PRIMOLUT N TABLET TABLET 90 35 150 30 5 71.400,00 357
363 T6280 PROBENID TABLET FC 500 MG TABLET 200 100 500 100 5 120.000,00 600
364 T0754 PRORENAL TABLET TABLET 0 650 4.400 100 44 540.000,00 23.760
365 S0083 PRORIS SIRUP 100 MG/5 ML 60 ML BOTOL 0 1 7 1 7 16.150,00 113
366 I2595 PROSOGAN INJEKSI AMPUL 90 43 202 1 202 74.575,93 15.064
367 Z0193 PULMICORT RESPULE 0,5 MG/ML VIAL 0 41 280 20 14 161.818,00 2.265
368 Z0504 PULMICORT TURBU I.H 200MCG PCS 0 1 6 1 6 84.545,50 507
369 I0978 PUREGON INJEKSI 100 IU AMPUL 0 2 15 5 3 3.404.425,50 10.213
370 I0504 PUREGON INJEKSI 50 IU VIAL 0 1 6 1 6 378.167,75 2.269
371 IA000000046 RECORMON PREFILLED SYRINGE 2000 IU VIAL 48 14 48 6 8 760.909,09 6.087
372 T0572 RENAX TABLET TABLET 0 13 100 50 2 166.500,00 333
373 I0498 RENXAMIN INJEKSI BOTOL 0 2 14 1 14 79.200,00 1.108
374 I0318 REOTAL INJEKSI 300 MG AMPUL 0 4 25 5 5 215.000,00 1.075
375 T0573 REOTAL SR 400 TABLET TABLET 0 18 120 30 4 224.000,00 896
376 TA000000051 REQUIP PD TABLET 4 MG TABLET 0 7 28 28 1 191.668,00 191
377 I0943 REXTA INJEKSI 50 MG VIAL 0 3 20 1 20 495.000,00 9.900
378 T0577 RHINOFED TABLET TABLET 0 179 1.200 50 24 77.000,00 1.848
alaman 14 dari 19

HARGA
P)
1

4.909.090,92
3.534.544,00
612.000,00
366.600,00
1.319.580,00
715.500,00
810.000,00
2.314.350,25
4.252.780,00
6.762.000,00
357.000,00
600.000,00
23.760.000,00
113.050,00
15.064.337,86
2.265.452,00
507.273,00
10.213.276,50
2.269.006,50
6.087.272,72
333.000,00
1.108.800,00
1.075.000,00
896.000,00
191.668,00
9.900.000,00
1.848.000,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:22 Halaman 15

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

379 T0578 RHINOS SR TABLET TABLET 0 104 700 50 14 225.000,00 3.150

380 T0912 RIMACTAZID TABLET 450/300MG TABLET 0 203 1.380 30 46 185.760,00 8.544
381 T0913 RIMSTAR TABLET TABLET 0 153 1.050 30 35 134.820,00 4.718
382 I0982 RINGERFUNDIN INFUS FLABOT 393 86 192 1 192 11.500,00 2.208
383 I0712 ROCULAX INJEKSI VIAL 0 3 20 10 2 922.500,00 1.845
384 T0584 ROVADIN TABLET TABLET 0 58 400 100 4 500.000,00 2.000
385 T0588 SALOFALK TABLET 250 MG TABLET 1.500 283 400 100 4 405.000,00 1.620
386 S0089 SANADRYL SIRUP BOTOL 18 3 2 1 2 8.590,00 17
387 T1433 SANDIMMUN NEORAL KAPSUL 100 MG KAPSUL 0 46 300 50 6 1.954.545,00 11.727
388 TA000000003 SANDIMMUN NEORAL KAPSUL 25 MG KAPSUL 1.200 563 2.650 50 53 545.455,00 28.909
389 T0593 SANTA E TABLET TABLET 0 525 3.600 100 36 74.500,00 2.682
390 T1055 SANTA E 400 TABLET TABLET 0 133 900 100 9 334.500,00 3.010
391 Z0154 SCABIMIDE 10 G KRIM TUBE 11 6 30 1 30 10.430,00 312
392 Z0155 SCABIMIDE 30 G KRIM TUBE 0 3 20 1 20 56.700,00 1.134
393 I2648 SEDACUM INJEKSI 15 MG/3 ML AMPUL 0 28 190 5 38 135.000,00 5.130
394 I2647 SEDACUM INJEKSI 5 MG/5 ML AMPUL 0 109 740 10 74 120.000,00 8.880
395 T1384 SELOXY AA KAPSUL KAPSUL 0 33 210 30 7 176.000,00 1.232
396 T0598 SELOXY TABLET TABLET 0 165 1.110 30 37 135.000,00 4.995
397 Z0507 SERETIDE DISKUS 100 BOTOL 1 7 47 1 47 91.666,00 4.308
398 Z0503 SERETIDE DISKUS 250 BOTOL 1 18 121 1 121 103.030,00 12.466
399 T0001 SEROLIN TABLET 10 MG TABLET 0 18 105 105 1 633.000,00 633
400 TA000000040 SEROQUEL TABLET 200 MG TABLET 0 20 120 10 12 183.609,08 2.203
401 I0856 SETROVEL INJEKSI 5 MG/5 ML AMPUL 0 58 390 10 39 450.000,00 17.550
402 I000000001 SEVODEX 250 ML BOTOL 11 7 37 1 37 1.960.000,00 72.520
403 I0823 SIBITAL INJEKSI 200 MG/2 ML AMPUL 0 24 160 10 16 90.000,00 1.440
404 TA000000033 SIFROL TABLET 0.375 MG TABLET 750 258 990 30 33 196.363,64 6.480
405 T1450 SIMARC TABLET 2 MG TABLET 0 1.733 11.800 100 118 81.900,00 9.664
alaman 15 dari 19

HARGA
P)
1

3.150.000,00
8.544.960,00
4.718.700,00
2.208.000,00
1.845.000,00
2.000.000,00
1.620.000,00
17.180,00
11.727.270,00
28.909.115,00
2.682.000,00
3.010.500,00
312.900,00
1.134.000,00
5.130.000,00
8.880.000,00
1.232.000,00
4.995.000,00
4.308.302,00
12.466.630,00
633.000,00
2.203.308,96
17.550.000,00
72.520.000,00
1.440.000,00
6.480.000,12
9.664.200,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:22 Halaman 16

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

406 T0925 SIRDALUD TABLET 2 MG TABLET 200 125 700 100 7 764.446,00 5.351
407 I0230 SNMC INJEKSI AMPUL 0 47 320 1 320 78.210,00 25.027
408 I0691 SOJOURN 250 ML BOTOL 13 4 14 1 14 1.199.900,00 16.798
409 I0916 SOMATOSTATIN INJEKSI VIAL 0 4 27 1 27 668.800,00 18.057
410 T0927 SPASMOMEN TABLET TABLET 0 30 210 30 7 186.000,00 1.302
411 YA000000003 SPIRIVA 18 MCG COMBO + HANDIHALER BOX 95 53 265 1 265 138.675,45 36.748
412 TA000000030 STALEVO TABLET TABLET 0 188 1.290 30 43 242.727,00 10.437
413 T0675 STELAZINE TABLET 5 MG TABLET 0 450 3.100 100 31 94.833,75 2.939
414 Z0295 STERIMAR NASAL HYGIENE BOTOL 23 9 38 1 38 94.050,00 3.573
415 N0017 STESOLID INJEKSI 10 MG / 2ML AMPUL 0 79 535 5 107 52.000,00 5.564
416 N0018 STESOLID RECTAL 5 MG/2,5 ML TUBE 80 14 15 5 3 52.390,80 157
417 T1500 STOBLED TABLET TABLET 0 89 608 16 38 102.600,00 3.898
418 T0626 STOMACAIN TABLET TABLET 0 17 100 100 1 99.000,00 99
419 I0343 STREPTASE INJEKSI 1.500.000 IU / VIAL VIAL 14 3 6 1 6 2.990.909,08 17.945
420 I0967 SULBACEF INJEKSI 500 MG VIAL 0 1 5 1 5 169.750,00 848
421 T0934 SULCOLON TABLET TABLET 0 117 800 100 8 679.000,00 5.432
422 IA000000008 SUPRANE 240 ML VIAL 4 1 3 1 3 2.517.500,00 7.552
423 I*000000001 SURVANTA INJEKSI AMPUL 1 1 6 1 6 2.881.101,00 17.286
424 YA000000010 SYMBICORT 160/4,5 DOSE BOTOL 164 31 47 1 47 106.909,00 5.024
425 T6355 TALION TABLET 10 MG TABLET 0 3 30 30 1 72.150,00 72
426 I2675 TAMOLIV INFUS BOTOL 0 97 660 1 660 38.000,00 25.080
427 T0965 TANAPRES TABLET 10 MG TABLET 8.670 1.935 4.500 30 150 106.581,82 15.987
428 T0940 TANAPRESS TABLET 5 MG TABLET 4.920 843 810 30 27 57.818,18 1.561
429 Z0162 TANTUM VERDE SOL BOTOL 0 2 14 1 14 21.000,00 294
430 I2603 TAPROS INJEKSI 1,88 MG VIAL 3 1 4 1 4 636.344,10 2.545
431 I0946 TAPROS INJEKSI 11,25 MG (3M) VIAL 5 2 9 1 9 2.454.255,17 22.088
432 I0506 TAPROS INJEKSI 3,75 MG VIAL 6 5 28 1 28 454.406,70 12.723
alaman 16 dari 19

HARGA
P)
1

5.351.122,00
25.027.200,00
16.798.600,00
18.057.600,00
1.302.000,00
36.748.994,25
10.437.261,00
2.939.846,25
3.573.900,00
5.564.000,00
157.172,40
3.898.800,00
99.000,00
17.945.454,48
848.750,00
5.432.000,00
7.552.500,00
17.286.606,00
5.024.723,00
72.150,00
25.080.000,00
15.987.273,00
1.561.090,86
294.000,00
2.545.376,40
22.088.296,53
12.723.387,60
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:22 Halaman 17

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

433 Z0164 TARIVID TETES TELINGA BOTOL 40 16 69 1 69 44.091,00 3.042

434 TA000000037 TASIGNA HGC KAPSUL 200 MG CAPSUL 252 285 1.680 28 60 9.695.000,00 581.700
435 I0349 TAXEGRAM INJEKSI 1 GRAM VIAL 0 4 24 1 24 90.907,26 2.181
436 T1051 TEBOKAN SPECIAL TABLET TABLET 0 78 540 30 18 319.500,00 5.751
437 T0638 TELFAS OD TABLET TABLET 0 17 100 100 1 698.225,78 698
438 I0351 TERFACEF INJEKSI VIAL 0 55 374 1 374 127.275,19 47.600
439 Z0201 TERMISIL KRIM 10 GRAM TUBE 0 1 7 1 7 46.000,00 322
440 I0508 TETAGAM INJEKSI 250 IU/AMPUL VIAL 0 1 5 1 5 154.545,47 772
441 T0645 THERAGRAN M TABLET TABLET 100 75 400 100 4 359.100,00 1.436
442 Z0166 THROMBOPHOB GEL 20 GRAM TUBE 8 6 33 1 33 45.360,00 1.496
443 T0656 THYROZOL TABLET 10 MG TABLET 400 467 2.800 100 28 103.182,00 2.889
444 Z0172 TIMOLOL TETES MATA 0.5 % 5 ML BOTOL 0 4 27 1 27 47.750,00 1.289
445 Z0050 TOBROZON MINI DOSE STRIP 0 3 20 1 20 29.000,00 580
446 S0303 TRACETATE SUSPENSI 200 ML BOTOL 0 1 6 1 6 343.000,00 2.058
447 I0364 TRANEXID 10 % INJEKSI AMPUL 0 8 40 10 4 81.000,00 324
448 T1057 TREMENZA TABLET TABLET 0 258 1.800 100 18 100.000,00 1.800
449 T0861 TRIBESTAN TABLET TABLET 0 20 120 20 6 250.000,00 1.500
450 T0677 TRILEPTAL FCT TABLET 300 MG TABLET 0 8 50 50 1 408.172,00 408
451 T1058 TRIZEDON MR TABLET TABLET 0 50 360 60 6 196.000,00 1.176
452 Z0051 TROPIN TETES MATA 1 % 5 ML BOTOL 4 2 10 1 10 12.500,00 125
453 T0956 TROPINEURON TABLET TABLET 0 17 100 100 1 133.000,00 133
454 I0372 TUTOFUCIN OPS BOTOL 10 15 90 5 18 170.454,54 3.068
455 T6299 TUZALOS KAPLET KAPLET 0 33 200 100 2 64.000,00 128
456 I0973 TYGASIL INJEKSI 50 MG VIAL 26 10 40 10 4 5.775.000,00 23.100
457 S0098 ULTILOX SIRUP 150 ML BOTOL 0 13 88 1 88 23.750,00 2.090
458 T1087 ULTRACET KAPLET KAPLET 60 183 1.170 30 39 213.515,00 8.327
459 I0572 ULTRAVIST INJEKSI 300 MG 50 ML VIAL 30 9 30 10 3 1.120.000,00 3.360
alaman 17 dari 19

HARGA
P)
1

3.042.279,00
581.700.000,00
2.181.774,24
5.751.000,00
698.225,78
47.600.921,06
322.000,00
772.727,35
1.436.400,00
1.496.880,00
2.889.096,00
1.289.250,00
580.000,00
2.058.000,00
324.000,00
1.800.000,00
1.500.000,00
408.172,00
1.176.000,00
125.000,00
133.000,00
3.068.181,72
128.000,00
23.100.000,00
2.090.000,00
8.327.085,00
3.360.000,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:22 Halaman 18

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

460 T0690 URDAFALK TABLET 250 MG TABLET 0 15 90 30 3 284.350,00 853

461 TA000000008 URDAHEX KAPSUL KAPSUL 300 128 570 30 19 245.000,00 4.655
462 T1432 UROGETIX 100 MG TABLET TABLET 0 25 200 100 2 429.900,00 859
463 I0824 UROMITEXAN INJEKSI 400 MG AMPUL 285 85 300 15 20 1.022.700,00 20.454
464 TA000000056 UTROGESTAN KAPSUL 200 MG (ORAL/VAGINAL) CAPSUL 0 19 120 15 8 206.625,00 1.653
465 T5326 V BLOC TABLET TABLET 0 140 960 30 32 37.091,00 1.186
466 N0019 VALISANBE TABLET 5 MG TABLET 0 292 2.000 100 20 24.000,00 480
467 I0896 VANCEP INJEKSI 500 MG VIAL 94 18 28 2 14 221.800,00 3.105
468 I0525 VASCON INJEKSI AMPUL 0 3 20 5 4 416.500,00 1.666
469 S0069 VECTRIN SYRUP BOTOL 0 1 7 1 7 34.000,00 238
470 T0698 VECTRINE KAPSUL 300 MG KAPSUL 0 342 2.320 20 116 77.000,00 8.932
471 I0995 VENODENOL 3% INJEKSI AMPUL 30 18 90 5 18 220.500,00 3.969
472 T1090 VENOSMIL KAPLET KAPLET 0 22 160 20 8 145.000,00 1.160
473 Z0317 VENTOLIN INHALER BOTOL 47 38 211 1 211 57.955,00 12.228
474 Z0171 VENTOLIN NEBULIZER VIAL 20 28 180 20 9 120.000,00 1.080
475 I0904 VERORAB INJEKSI AMPUL 0 2 14 1 14 70.909,00 992
476 T1440 VIAGRA TABLET 50 MG TABLET 4 2 12 4 3 385.055,00 1.155
477 T1505 VIPALBUMIN TABLET TABLET 930 320 1.260 30 42 156.750,00 6.583
478 T0978 VOLTAREN SR75 TABLET TABLET 100 25 50 50 1 358.675,00 358
479 I0388 VOLTAREN INJEKSI AMPUL 0 1 5 5 1 194.610,00 194
480 S0101 VOMETA DROPS BOTOL 0 1 7 1 7 37.500,00 262
481 T0979 VOMETA FLASH TABLET TABLET 400 175 800 50 16 180.000,00 2.880
482 T1103 XELODA TABLET TABLET 9.720 2.680 8.520 120 71 3.000.000,00 213.000
483 Z0054 XITROL 5 ML TETES MATA BOTOL 24 36 221 1 221 27.250,00 6.022
484 I0392 XYLOCAIN INJEKSI 2 % 20 ML AMPUL 0 1 5 5 1 266.388,00 266
485 I0393 XYLOCAIN SPRAY 10 % 50 ML BOTOL 4 2 10 1 10 129.079,78 1.290
486 T0727 ZEGAVIT TABLET TABLET 0 29 150 50 3 115.000,00 345
alaman 18 dari 19

HARGA
P)
1

853.050,00
4.655.000,00
859.800,00
20.454.000,00
1.653.000,00
1.186.912,00
480.000,00
3.105.200,00
1.666.000,00
238.000,00
8.932.000,00
3.969.000,00
1.160.000,00
12.228.505,00
1.080.000,00
992.726,00
1.155.165,00
6.583.500,00
358.675,00
194.610,00
262.500,00
2.880.000,00
213.000.000,00
6.022.250,00
266.388,00
1.290.797,80
345.000,00
Dicetak Oleh : WENI Hari :Kamis Tanggal : 27/Aug/2015 Jam : 08:17:22 Halaman 19

RSUD Dr. MOEWARDI

Jln. Kol. Sutarto No. 132 Surakarta 57126
Telp: (0271) 634634, Fax: (0271) 637412,

LAMPIRAN USULAN KEBUTUHAN OBAT GOLONGAN OBT NON GNRK FORMULARIUM

SUMBER PENDANAAN BLUD
BULAN MEI TAHUN 2015
Tanggal 30 April 2015

No. KODE NAMA OBAT SATUAN STOK RERATA USULAN INDEKS USULAN HARGA BOX JUMLAH HARGA
GUDANG 30/04/2015 (BOX) (RP) (RP)
1 2 3 4 5 6 7 8 9 10 11

487 T0958 ZEMYC KAPSUL 150 MG TABLET 0 4 27 3 9 165.300,00 1.487

488 S0197 ZINKID SIRUP BOTOL 0 2 14 1 14 13.618,18 190
489 I0535 ZOLADEX INJEKSI 3,6 MG VIAL 14 6 27 1 27 763.546,25 20.615
490 I0419 ZOMETA INJEKSI 4 MG BOX 16 9 45 1 45 818.181,83 36.818
491 IA000000005 ZOVIRAC INJEKSI AMPUL 0 2 10 5 2 950.000,00 1.900
TOTAL BIAYA BARANG OBT NON GNRK FORMULARIUM : 8.676.280.5
Ppn (10 %) : 867.628.0
TOTAL BIAYA BARANG OBT NON GNRK FORMULARIUM + Ppn (10 %) : 9.543.908.6

TOTAL BARANG: 8.676.280.5

P p n (1 0 % ) : 867.628.0
T O T A L B A R A N G + P p n (1 0 % ) : 9.558.570.8
alaman 19 dari 19

HARGA
P)
1

1.487.700,00
190.654,52
20.615.748,75
36.818.182,35
1.900.000,00
676.280.568,01
867.628.056,80
543.908.624,81

676.280.568,01
867.628.056,80
558.570.833,21