RENCANAN BELANJA KESEHATAN MASYARAKAT

RENCANA ANGGARAN BIAYA 201
KEGIATAN : JAMINAN PELAYANAN KESEHATAN BANY

OBYEK BELANJA : BELANJA BAHAN DA
Program : Program Upaya Kesehatan Masyarakat

Kegiatan : Jaminan Kesehatan Nasional ( JKN )
No Item Formulasi dan Sediaan Satuan
1 air untuk injeksi cairan inj botol
2 Albendazol tab 400 mg Tablet
3 albendazol sir 200 mg/5mL botol
4 alopurinol tab 100 mg tablet
5 alopurinol tab 300 mg tablet
6 aminofilin cairan inj 24 mg/mL ampul
7 aminofilin tab 200 mg Tablet
8 amlodipin tab 5 mg tablet
9 amlodipin tab 10 mg tablet
10 amoksisilin tab 250 mg tablet
11 amoksisilin tab 500 mg tablet
12 amoksisilin sir kering 125 mg/5 mL botol

13 amoksisilin sir kering 250 mg/5 mL botol
14 antasida syr sir botol
15 antasida tablet tab kunyah tablet
16 antifungi / salep 3-6 salep tube
17 asam asetilsalisilat (asetosal) tab 80 mg tablet
18 asam askorbat (vitamin C) tab 50 mg tablet
19 asam askorbat (vitamin C) tab 250 mg tablet
20 asam folat tab 1 mg Tablet
21 asam mefenamat kapl 500 mg tablet
22 asiklovir tab 200 mg tablet
23 asiklovir tab 400 mg tablet
24 atapulgit tab tab 600 mg tablet
25 atenolol tab 50 mg tablet
26 atropin cairan inj i.v./i.m./s.k. 0,25 mg/mL ampul
27 bedak salisil serb 2% pot
28 benzatin benzil penisilin cairan inj i.m. 2,4 juta UI/mL vial
29 betametason krim 0,1% tube
30 bisakodil sup 5 mg supp
31 bisakodil sup 10 mg supp
32 Bisakodil tab 5 mg Tablet
33 captopril tab 12,5 mg tablet
34 captopril tab 25 mg tablet

35 deksametason cairan inj i.v./i.m. 5 mg/mL ampul
36 deksametason tab 0,5 mg tablet
37 diazepam lar rektal 5 mg/2,5 mL botol

38 diazepam lar rektal 10 mg/2,5mL botol
39 Diazepam tab 5 mg Tablet
40 dietilkarbamazin tab 100 mg tablet
41 difenhidramin cairan inj i.v./i.m. 10 mg/mL ampul
42 digoksin tab 0,25 mg tablet
43 diltiazem tab 30 mg (HCl) tablet
44 Dimenhidrinat tab 50 mg Tablet
45 doksisiklin kaps 100 mg kapsul
46 domperidon tab 10 mg tablet
47 epinefrin (adrenalin) cairan inj i.v./i.m./s.k. 0,1% ampul
48 eritromisin sir kering 200 mg/5 mL botol
49 eritromisin tab 500 mg tablet
50 fenitoin kaps 100 mg kapsul

51 fenitoin cairan inj 50 mg/mL ampul
52 fenobarbital inj 50mg/ml ampul
53 fenoksimetil penisilin tab 500 mg Tablet
54 fenoksimetil penisilin tab 250 mg Tablet
55 fitomenadion inj 10 mg/ml Ampul
56 fitomenadion inj 2 mg/ml Ampul
57 fitomenadion (vitamin K1) tab salut 10 mg tablet
58 flufenazin cairan inj i.m. 25 mg/mL (dekanoat) ampul
59 fluoksetin tab 20 mg tablet
60 furosemid tab 40 mg tablet
61 garam oralit serb sachet
62 glimepirid 1 mg tab 1 mg tablet
63 glimepirid 2 mg tab 2 mg tablet
64 gliseril trinitrat tab 0,5 mg tablet
65 glukosa 5% lar infus botol
66 griseofulvin tab 125 mg Tablet
67 haloperidol 2 mg tablet
68 haloperidol 5 mg tablet
69 haloperidol tetes 2 mg/mL botol
70 haloperidol cairan inj i.m. 5 mg/mL (HCl) ampul
71 haloperidol cairan inj 50 mg/mL (dekanoat) ampul
72 haloperidol 1,5 mg tablet
73 hidroklorotiazid tab 25 mg tablet
74 hidrokortison krim 2,5% tube
75 ibuprofen tab 200 mg tablet
76 ibuprofen tab 400 mg tablet
77 ibuprofen susp 100 mg/5 ml botol
78 isoniazid tab 300 mg tablet
79 isoniazid tab 100 mg tablet

80 isosorbid dinitrat tab sublingual 5 mg tablet
81 isosorbid dinitrat tab sublingual 10 mg tablet
82 kalsium laktat (kalk) tab 500 mg tablet
83 karbamazepin tab 200 mg tablet
84 karbogliserin tetes telinga botol
85 ketokonazol tab 200 mg Tablet
86 ketokonazol krim 2% tube
87 kloramfenikol salep mata 1% tube
88 kloramfenikol susp 125 mg/5 mL botol

89 kloramfenikol tetes mata 0,5% botol
90 klorfeniramin tab 4 mg tablet
91 klorpromazin tab sal selaput 100 mg tablet
92 klorpromazin cairan inj i.m. 5 mg/mL ampul
93 Klindamisin 300 mg kapsul kapsul
94 kodein tab 10 mg tablet
95 kolkisin tab 500 mcg tablet
96 kotrimoksazol (dewasa) kombinasi tab 480 mg tablet
97 kotrimoksazol sirup susp 240 mg botol
98 lidokain cairan inj 2% ampul
99 lidokain kombinasi epinefrin cairan inj 2 mL ampul
100 loratadin tab 10 mg tablet
101 magnesium sulfat cairan inj i.v. 20% ampul

102 magnesium sulfat cairan inj i.v. 40% ampul
103 metformin tab 500 mg tablet
104 metformin tab 850 mg tablet
105 metilergometrin cairan inj 0,2 mg/mL ampul
106 metilprednisolon tab 4 mg tablet
107 Metocloperamid injeksi 5mg/ml Ampul
108 metoklopramid tab 10 mg tablet
109 metronidazol tab 250 mg tablet
110 metronidazol tab 500 mg tablet
111 metronidazol sir 125 mg/5 mL botol
112 metronidazol larutan infus infus 5mg/ml botol
113 nifedipin tab 10 mg tablet
114 nistatin tab vaginal 100.000 IU tablet
115 oksitosin cairan inj 10 IU/mL ampul
116 parasetamol tab 500 mg tablet
117 parasetamol sir 120 mg/5 ml botol
118 permetrin krim 5% tube
119 pirantel pamoat tablet 125 mg tablet

120 piridoksin (vitamin B6) tab 10 mg tablet
121 prednison tab 5 mg Tablet
122 ranitidin tab 150 mg tablet

retinol (vitamin A) kaps lunak 100.000 IU kapsul
123 kapsul lunak
124 ringer laktat lar infus botol
125 risperidon tab 2 mg tablet
126 salbutamol tab 2 mg tablet
127 salbutamol tab 4 mg tablet
128 salep 2-4 salep pot
129 serum anti bisa ular A.B.U.I vial
130 serum antitetanus (A.T.S) inj i.m. 1500 IU/mL vial
131 setirizin sir 5 mg/5 mL botol
132 sianokobalamin inj 500 mcg/ mL ampul
133 sianokobalamin tab 50mcg tablet
134 simvastatin tab sal selaput 20 mg tablet
135 simvastatin tab sal selaput 10 mg tablet
136 siprofloksasin tab sal selaput 500 mg tablet
137 spironolakton tab 25 mg tablet
138 tablet tambah darah (Fe Fumarat + asam folat) Tablet
139 tetrasiklin kaps 500 mg (HCl) kapsul
140 tetrasiklin kaps 250 mg (HCl) kapsul
141 thiamin (vitamin B1) tab 50 mg tablet
142 triheksifenidil tab 2 mg tablet
143 vitamin b kompleks tab kombinasi tablet
144 zinc tab dispersible 20 mg tablet
1 antihemoroid, kombinasi : suppositoria supp
2 Ampisillin Injeksi 1000 mg vial
3 amitriptilin tab sal selaput 25 mg tablet
4 antimigren kombinasi : ergotamin + kofein Tablet
5 Asam mefenamat 250 mg Tablet
6 Asam traneksamat tablet 500mg tablet
7 Diazepam inj. 5 mg/ml Ampul
8 Diazepam tab 2 mg Tablet
9 domperidon sir 5 mg/5 mL botol
10 etil klorida 100 ml botol
11 fenitoin 30 mg kaps. Tablet
12 fenobarbital 30mg tab Tablet
13 fenobarbital 100mg tab Tablet
14 furosemide inj 10mg/ml Ampul
15 Glibenklamid tab 5 mg Tablet
16 hidrogen peroksida cairan 3% botol
17 hiosin butilbromid tab 10 mg Tablet
18 Hyosin injeksi / buscopan inj Ampul
19 kalamin lotio botol
20 Klindamisin 150 mg kapsul kapsul
21 kloramfenikol kaps 250 mg kapsul
22 kloramfenikol tetes telinga botol
23 klorpromazin tab sal selaput 25 mg tablet
24 lidokain spray oral 10% botol
25 Metamizol injeksi / norages Ampul

26 metilergometrin tab 0,125 mg Tablet
27 natrium bikarbonat 500 mg Tablet
28 natrium diklofenak tab sal enterik 25 mg tablet
29 natrium diklofenak tab sal enterik 50 mg tablet
30 nistatin tab sal gula 500.000 UI/mL tablet
31 mikonazol krim 2% tube
32 parasetamol drops 60 mg/0,6 ml botol
33 perak sulfadiazin krim 1% tube
34 pirantel pamoat susp 125 mg/5 ml botol
35 pirantel pamoat tab 250 mg Tablet
36 propiltiourasil tab 100 mg Tablet
37 prokain benzilpenisilin serb inj i.m. 3 juta UI/viaL vial
38 propanolol tab 10 mg tablet
39 tetrakain tetes mata botol
Total Jumlah Uang Belanja E-Katalog
Pagu Anggaran
Sisa Mati Uang Belanja E-Katalog
Terbilang
Lisinopril 5 mg tab
Lisinopril 10mg tab
Valsartan tab
Kepala Bidang SDK Kepala UPTD Puskesmas Sumberberas
MUJITO, SKM
NIP. 19690524 199203 1 003
RENCANA ANGGARAN BIAYA 2017
ATAN : JAMINAN PELAYANAN KESEHATAN BANYUWANGI PUSKESMAS

OBYEK BELANJA : BELANJA BAHAN DAN OBAT
Harga Satuan Pabrikan Isi per kemasan JUMLAH
2,750.00 PT. Otsuka Indonesia/MUP dus, 120 ampul

392.00 PT. Holi Pharma dus, 30 tablet
3,849.00 PT. Indofarma/IGM dus, 10 botol
89.00 PT. Shamparindo Perdana/IGM dus, 100 tablet
210.00 PT. Sejahtera Lestari Farma dus, 100 tablet
2,998.00 PT. Phapros dus, 30 ampul
91.00 PT. Marin liza dus, 100 tablet
85.00 PT. Pertiwi Agung dus, 30 tablet
104.00 PT. Pharma Laboratories dus, 30 tablet
180.00 PT. Novapharin dus, 100 tablet
190.00 PT. Pharma Laboratories dus, 100 tablet
1,881.00 PT. Mersi Farma botol

3,473.00 PT. Holi Pharma botol
1,923.00 PT. Mersi Farma botol
58.00 PT. Mersi Farma dus, 100 tablet
4,323.00 PT. Marin liza pot
104.00 PT. Kimia farma dus, 100 tablet
114.00 PT. Tempo Scan Pasifik dus, 50 tablet
67.00 PT. Marin liza botol, 100 tablet
240.00 PT. Phapros dus, 50 tablet
140.00 PT. Zenith dus, 50 tablet
310.00 PT. Kalbe dus, 30 tablet
1,540.00 PT. Ethica Industri dus, 100 ampul
1,020.00 PT. Rama Emerald 1 dus
14,500.00 PT. Phapros dus, 10 vial
1,349.00 PT. Kimia farma dus, 25 tube
5,800.00 PT. Boehringer Ingelheim dus, 6 supp
5,800.00 PT. Boehringer Ingelheim dus, 50 supp
300.00 PT. Etercon Pharma botol, 30 tablet
80.00 PT. Pertiwi dus, 100 tablet
1,567.00 PT. Bernofarm dus, 100 ampul
41.00 PT. PROMEDRAHARDJO FARMASI INDUSTRI dus, 100 tablet
12,090.00 PT. Actavis Indonesia dus, 5 alubag
17,577.00 PT. Actavis Indonesia dus, 5 alubag

104.00 PT. Yarindo Farmatama dus, 100 tablet
99.00 PT. Kimia farma botol, 100 tablet
268.00 PT. Indofarma/IGM dus, 100 kapsul
95.00 PT. Dexa Medica dus, 100 tablet
6,150.00 PT. Phyto Kemo Agung Farma botol
730.00 PT. Rama Emerald dus, 100 tablet
152.00 PT. Ikapharmindo botol, 100 tablet

57,500.00 PT. Mersi Farma dus, 5 ampul
225.00 PT. PROMEDRAHARDJO FARMASI INDUSTRI dus, 30 tablet
80.00 PT. Shamparindo Perdana/IGM dus, 100 tablet
260.00 PT. Rama Emerald dus, 100 sachet
194.00 PT. Hexparm Jaya dus, 50 tablet
231.00 PT. Guradian dus, 50 tablet
1,350.00 PT. Actavis Indonesia dus, 30 tablet
6,900.00 PT. Widatra Bhakti dus, 20 botol
18,000.00 PT. Mersi Farma dus, 1 botol
4,000.00 PT. Mersi Farma dus, 12 ampul
97,500.00 PT. Soho Industri dus, 5 ampul
111.00 PT. Phyto Kemo Agung Farma dus, 100 tablet
2,475.00 PT. Rama Emerald dus, 1 botol
90.00 PT. Yarindo Farmatama dus, 100 tablet
198.00 PT. Pratapa Nirmala dus, 100 tablet
2,500.00 PT. Lucas Jaya botol
4,700.00 PT. Novapharin dus, 1 botol

29,330.40 PT. Harsen dus, 10 botol
36.00 PT. Imfarmind dus, 200 tablet
2,750.00 PT. Lapi dus, 30 tablet
2,286.00 PT. Holi Pharma dus, 1 botol
1,937.00 PT. Lucas Djaja dus, 30 ampul
123.00 PT. Bernofarm dus, 50 tablet

150.00 PT. Molex Ayus dus, 100 tablet
3,800.00 PT. Meprofarm dus, 1 botol 60ml
8,525.00 PT. Fima botol 100ml
1,010.00 PT. Mersi Farma dus, botol 60ml
12,155.00 PT. Galenium Farmasi dus, 60 tube
284.00 PT. Kimia farma
botol, 50 kapsul
7,150.00 PT. Widatra Bhakti dus, 20 botol
2,527.00 PT. Marin liza 1 pot
462,000.00 PT. Biofarma dus, 1 vial
126,500.00 PT. Biofarma dus, 10 ampul
3,150.00 PT. Erela botol, 60 ml
1,087.00 PT. Lucas Djaja dus, 100 ampul
51.00 PT. Marin liza dus, 100 tablet
229.00 PT. Natura dus, 100 tablet
3,350.00 PT. Kimia farma
11,150.70 Bernofarm
157.00 PT. Yarindo Farmatama
294.80 Kimia Farma
332.20 AFI
4,766.30 Kalbe
16,359.20 Stesolid
162.80 OGB
3,624.00 PT. Novapharin
135,015.10 Walter Ritter
794.20 OGB
153.00 Indofarma
215.00 Indofarma
1,751.00 Infdofarma
158.40 Indofarma
33,323.40 Onemed
2,780.80 Meprofarma
42,743.80 Boehringer
17,220.50 yupharin
737.00 OGB
618.20 Kimia Farma
26,886.20 interbat
163.00 PT. Phapros
443,756.50 astra zeneca
12,707.20 Meprofarma
635.80 landson
72.60 PIM
160.00 PT. Phapros
175.00 PT. Phapros
820.00 PT. Phapros
3,575.00 PT. Kimia farma
5,720.00 PT. Indofarma/IGM
70,684.90 Darya Varia
19,792.30 Pfizer
7,793.50 Pfizer
460.90 Indofarma
9,477.00 PT. Phapros
66.00 PT. Holi Pharma
19,259.90 Cendo
epala UPTD Puskesmas Sumberberas

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RENCANA ANGGARAN BIAYA 201

KEGIATAN : JAMINAN PELAYANAN KESEHATAN BANY

Program : Program Upaya Kesehatan Masyarakat

No Item Formulasi dan Sediaan Satuan

1 air untuk injeksi cairan inj botol

2 Albendazol tab 400 mg Tablet

3 albendazol sir 200 mg/5mL botol

4 alopurinol tab 100 mg tablet

5 alopurinol tab 300 mg tablet

6 aminofilin cairan inj 24 mg/mL ampul

7 aminofilin tab 200 mg Tablet

8 amlodipin tab 5 mg tablet

9 amlodipin tab 10 mg tablet

10 amoksisilin tab 250 mg tablet

11 amoksisilin tab 500 mg tablet

12 amoksisilin sir kering 125 mg/5 mL botol

15 antasida tablet tab kunyah tablet

16 antifungi / salep 3-6 salep tube

17 asam asetilsalisilat (asetosal) tab 80 mg tablet

18 asam askorbat (vitamin C) tab 50 mg tablet

19 asam askorbat (vitamin C) tab 250 mg tablet

20 asam folat tab 1 mg Tablet

21 asam mefenamat kapl 500 mg tablet

22 asiklovir tab 200 mg tablet

23 asiklovir tab 400 mg tablet

24 atapulgit tab tab 600 mg tablet

25 atenolol tab 50 mg tablet

26 atropin cairan inj i.v./i.m./s.k. 0,25 mg/mL ampul

27 bedak salisil serb 2% pot

29 betametason krim 0,1% tube

30 bisakodil sup 5 mg supp

31 bisakodil sup 10 mg supp

32 Bisakodil tab 5 mg Tablet

33 captopril tab 12,5 mg tablet

34 captopril tab 25 mg tablet

36 deksametason tab 0,5 mg tablet

37 diazepam lar rektal 5 mg/2,5 mL botol

40 dietilkarbamazin tab 100 mg tablet

41 difenhidramin cairan inj i.v./i.m. 10 mg/mL ampul

42 digoksin tab 0,25 mg tablet

43 diltiazem tab 30 mg (HCl) tablet

44 Dimenhidrinat tab 50 mg Tablet

45 doksisiklin kaps 100 mg kapsul

46 domperidon tab 10 mg tablet

47 epinefrin (adrenalin) cairan inj i.v./i.m./s.k. 0,1% ampul

48 eritromisin sir kering 200 mg/5 mL botol

49 eritromisin tab 500 mg tablet

50 fenitoin kaps 100 mg kapsul

53 fenoksimetil penisilin tab 500 mg Tablet

54 fenoksimetil penisilin tab 250 mg Tablet

55 fitomenadion inj 10 mg/ml Ampul

56 fitomenadion inj 2 mg/ml Ampul

57 fitomenadion (vitamin K1) tab salut 10 mg tablet

58 flufenazin cairan inj i.m. 25 mg/mL (dekanoat) ampul

59 fluoksetin tab 20 mg tablet

60 furosemid tab 40 mg tablet

61 garam oralit serb sachet

62 glimepirid 1 mg tab 1 mg tablet

63 glimepirid 2 mg tab 2 mg tablet

64 gliseril trinitrat tab 0,5 mg tablet

65 glukosa 5% lar infus botol

66 griseofulvin tab 125 mg Tablet