Lampiran srt, No.

14/UM 000/9000/I/2019
DAFTAR HNA & FEE DISTRIBUSI KFTD PRODUK GENERIK TAHUN 2019

NO. NAMA PRODUK KEMASAN

HNA 2019

I. PRODUK REGULER OGB D

1 Acyclovir 200 mg Tablet Dus 100 tabl 59,638

2 Acyclovir 400 mg Tablet Dus 100 tabl 87,776
3 Acyclovir Cream Tube 5 gram 3,948
4 ALBENDAZOLE TABLET KUNYAH 400 DUS 10X10 TABL 40,600
5 ALLOPURINOL 100/250 MG DUS 10X10 TABL 18,720
6 Alprazolam 0.5 mg tablet Dus 100 tabl 53,182
7 Alprazolam 1 mg Tablet Dus 100 tabl 81,818
8 AMBROXOL 30/230 MG DUS 10X10 TABL 14,121
9 AMBROXOL SIRUP BTL 60 ML 4,556
10 AMLODIPINE 5/80 MG TABLET DUS 5X10 TABL 43,636
11 AMLODIPINE 10/120 MG TABLET DUS 5X10 TABL 76,945
12 Amoxicillin 500 mg Kaplet Dus 100 tabl 47,168
13 Ampicillin 500 mg Tablet Dus 100 tabl 48,395
14 ANTALGIN 500 MG TABLET DUS 10X10 TABL 28,008
15 ANTASIDA DOEN DUS 10X10 TABL 19,145
16 Antasida DOEN Suspensi Fles 60 ml 10,445
17 ANTIHEMOROID SUPP 2G DUS 10 SUPP 30,000
18 Azithromycin 500 mg Kapsalsel Dus 20 kapl 200,000
19 BETAMETASON 0,1% KRIM TUBE 5 GRAM 2,327
20 CAPTOPRIL 12.5 MG DUS 10X10 TABL 10,227
21 CAPTOPRIL 25 MG DUS 10X10 TABL 13,149
22 Cefadroxil 500 mg Kapsul Dus 50 kaps 71,578
23 Cefixime 100 mg Kapsul Dus 30 kaps 65,307
24 Cetirizine 10 mg Tabsalsel Dus 30 Tabl 12,600
25 CHLORAMPHENICOL SUSPENSI BTL 60 ML 8,135
26 CHLORAMPHENIKOL 250 MG KAPSUL DUS 10X10 KAPS 61,985
27 CHLOROQUIN 150/300 MG DUS 10X10 TABL 28,303
28 CHLORPROMAZIN 100/400 MG DUS 10X10 TABL 24,025
29 CIMETIDINE 200/250 MG. DUS 10X10 TABL 17,515
30 Ciprofloxacin 500mg Tabsalsel Dus 50 tabsal 32,000
31 CLONIDINE 0.15 MG. DUS 10X10 TABL 18,636
32 CLOPIDOGREL 75 MG DUS 3X10 TABL 270,000
33 Codein 10 mg Tablet (strip) DUS 10X10 TABL 62,270
34 Codein 15 mg Tablet (Strip) DUS 10X10 TABL 112,180
35 Codein 20 mg Tablet (Strip) DUS 10X10 TABL 147,600
36 COTRIMOXAZOLE ADULT DUS 10X10 TABL 24,928
37 COTRIMOXAZOLE SUSPENSI BTL 60 ML 6,050
38 DEXAMETHASONE 0.5 MG DUS 10X10 TABL 10,677
39 Diazepam 2 mg Tablet (100) BTL 100 tabl 12,355
40 DILTIAZEM 30/200 MG DUS 10X10 TABL 18,628
41 DIMENHYDRINATE 50 MG BTL 100 TABL 12,980
42 Doxycycline 100 mg Kapsul Dus 100 kaps 60,018
43 EPHEDRIN 25 MG TABLET DUS 10 x 10 tablet 15,636
44 ERGOTAMINE COFFEINE BTL 100 TABL 20,350
45 Erythromycin 250 mg Kapsul Dus 100 kaps 88,296
46 Erythromycin Sirup Kering Fles 60 ml 12,474
47 ETHAMBUTOL 250 MG. DUS 20X10 TABL 83,496
48 ETHAMBUTOL 500 MG. DUS 10X10 TABL 76,138
49 Fenobarbital tablet 30 mg Dus 10 x 10 tablet 21,818
50 FERROSUS SULFHATE TABLET 300 MG BOTOL 100 8,168
51 Fluconazole 150 mg Kapsul Dus 10 kaps 200,003
52 FUROSEMIDE 40 MG. DUS 20X10 TABL 24,240
53 GENTAMISIN SULFAT 0,1% KRIM TUBE 5 GRAM 3,319
54 Glibenclamide 5 mg Tablet Dus 100 tabl 21,736
55 Glimepiride 1 mg Tablet Dus 50 tabl 34,549
56 Glimepiride 2 mg Tablet Dus 50 tabl 65,149
57 Glimepiride 3 mg Tablet Dus 50 tabl 88,840
58 Glimepiride 4 mg Tablet Dus 50 tabl 118,454
59 GLYCERIL GUAIKOLAT DUS 10 x 10 tablet 21,353
60 GRISEOFULVIN 125/175 MG DUS 10X10 TABL 46,999
61 HIDROKORTISON ASETAT 2,5% KRIM TUBE 5 GRAM 3,498
62 HYDROCHLOROTHIAZIDE 25 MG DUS 10X10 TABL 11,636
63 IODINE POVIDON 10% BTL 30 ML 5,940
64 IODINE POVIDON 10% BTL 60 ML 6,550
65 IODINE POVIDON 10% BTL 300 ML 18,070
66 IODINE POVIDON 10% BTL 1000 ML 54,515
67 ISONIAZID (INH) 100/250 MG DUS 10X10 TABL 12,960
68 ISONIAZIDE 300 MG DUS 100 TAB 17,300
69 Kalsium Laktat tablet 500 mg* Dus 10 x 10 tablet 20,362
70 KETOCONAZOLE 200/300 MG DUS 5X10 TABL 25,530
71 KETOKONAZOLE 2% KRIM TUBE 10 GRAM 5,100
72 KLORAMFENIKOL SM 1% (STERIL) TUBE 5 GRAM 4,725
73 LEVOFLOXACIN 500/700 MG DUS 5X10 TABL 52,440
74 Lidocain 2% Injeksi Dus 100 ampul 200,808
75 MELOXICAM 15/150 MG DUS 2X10 TABL 25,045
76 MELOXICAM 7,5/75 MG DUS 2X10 TABL 14,452
77 Methylergometrine 0,125 mg Dus 100 tabl 24,600
78 METOCLOPRAMID 10 MG DUS 10X10 TABL 13,000
79 METOCLOPRAMIDE 5/100 MG-BLISTE DUS @ 10 BLIS X 10 TAB 11,500
80 METRONIDAZOLE 250 MG. DUS 10X10 TABL 18,200
 81 METRONIDAZOLE 500 MG. DUS 10X10 TABL 26,000
82 MICONAZOLE KRIM 2% TUBE 10 GRAM 3,250
83 Morfina 10 mg/ml Injeksi Dus 10 x 1 ml 95,449
84 Morphine 10 mg Tablet Fles 30 tabl 32,890
85 Natrium Diklofenak 25 mg TSE Dus 50 tabl 16,645
86 Natrium Diklofenak 50 mg TSE Dus 50 tabl 20,835
87 NIFEDIPIN 10 MG. DUS 10X10 TABL 17,590
88 OKSITETRASIKLIN SK 3% TUBE 5 GRAM 2,193
89 OKSITETRASIKLIN SM 1% TUBE 3,5 GRAM 4,235
90 Omeprazole 20 mg Kapsul Dus 30 kaps 19,210
91 ORALIT 200 ML DUS 100 SASE 71,855
92 PAPAVERIN 40/190 MG DUS 10X10 TABL 15,116
93 PARACETAMOL SYRUP BTL 60 ML 4,605
94 PARASETAMOL 500 MG TABLET DUS 10X10 TABL 26,085
95 Pethidin HCl 50 mg/ml Injeksi Dus 10 x 2 ml 119,922
96 PIROXICAM 10 MG DUS 10X10 TABL 12,093
97 PIROXICAM 20 MG DUS 10X10 TABL 14,226
98 PREDNISON TABLET 5 MG DUS 10X10 TABL 13,091
99 Propranolol HCl 40 mg Tablet Dus 100 tabl 27,265
100 PYRANTEL 125 MG. DUS 25X4 TABL 36,810
101 PYRAZINAMIDE 500/700 MG. DUS 10X10 TABL 31,285
102 PYRIDOXINE (Vit B6) TABLET 10 MG DUS 10 x 10 tablet 13,455
103 PYRIDOXINE (Vit B6) TABLET 10 MG DUS 10 x 10 tablet 13,455
104 QUININE 222 MG DUS 10X6 TABL 40,200
105 Quinine 25% Injeksi Dus 100 ampul 392,204
106 RANITIDIN 150/250 MG DUS 3X10 TABL 12,600
107 Rifampicin 450 mg Tabsalsel Dus 100 kapl 165,048
108 Rifampicin 600 mg Tabsalsel Dus 100 kapl 235,485
109 SALBUTAMOL 2 MG. DUS 10X10 TABL 7,639
110 SALBUTAMOL 4 MG. DUS 10X10 TABL 9,130
111 SALISIL BEDAK 2% KOTAK 50 GR 3,300
112 SIMVASTATIN 10/100 MG DUS 5X10 TABL 23,318
113 SIMVASTATIN 20/200 MG DUS 5X10 TABL 46,636
114 SULFADOXINE PYRIMETHAMINE DUS 10X10 TABL 91,200
115 Tetracycline 250 mg Kapsul Dus 100 kaps 42,950
116 Tetracycline 500 mg Dus 100 kaps 122,200
117 Tramadol 50 mg Kapsul Dus 50 kaps 25,730
118 VERAPAMIL 80 MG. DUS 10X10 TABL 43,809
119 VITAMIN B KOMPLEKS SUPLEMEN DUS 10X10 TABL 13,090
120 VITAMIN B1 100/225 MG DUS 10X10 TABL 24,700
121 VITAMIN B1 50/125 MG DUS 10X10 TABL 14,215
122 VITAMIN B12 0.05/100 MG DUS @ 10X10 TAB 7,105
123 VITAMIN C 100/140 MG DUS 10X10 TABL 11,040
124 VITAMIN C 250/350 MG DUS 10X10 TABL 14,914
125 VITAMIN C 50 SUPLEMEN DUS 10X10 TABL 11,440
126 VITAMIN C 50/100 MG DUS 10X10 TABL 15,301
127 Zink Dispersibel Tablet Dus 100 tabl 43,182

II. PRODUK OGB TENDER D

128 DIETHYLCARBAMAZINE 100 MG DUS 10X10 TABL 20,000
129 EUGENOL CAIRAN BTL 10 ML 24,000
130 LAMIVUDINE 150 MG Btl 60 tabl 120,000
131 RETINOL (VITAMIN A 200.000 UI) BTL 50 KAPS 37,650
132 RETIONOL (VITAMIN A 100.000 UI) BTL 50 KAPS 22,500
133 YODIUM TES BTL 10 ML 10,000
134 YODIUM TES KIT BTL 6X10 ML 60,000
135 Zidovudine 100 mg Kapsul Btl 60 kaps 140,000
136 Tablet Tambah Darah NEO Dus 10 strip @ 10 TSG 50,000
137 Nevirapine 200 MG Btl 60 tabl 180,000
138 Kombinasi Lamivudine 150 mg + Zidovudine 300 mg Btl 60 tabl 300,000
139 Efavirens 600 mg Botol 30 tabl 250,000
140 Kombinasi Cefixime 400 mg + Azitromycin 1000 mg Paket 50,000
141 Lamivudine 100 mg Btl 60 tabl 80,000
142 Tenofovir Disoproxil Fumarate 300 MG TSS Btl 60 tabl 300,000

143 Obat Anti Tuberculosis FDC Kategori Anak Paket 350,000

144 Obat Anti Tuberculosis FDC Kategori 1 Paket 600,000

145 Obat Anti Tuberculosis FDC Kategori 2 Paket 1,800,000

III. PRODUK REGULER KOMODITI D

146 BETASON - N KRIM TUBE 5 GRAM 12,250
147 BETASON KRIM TUBE 5 GRAM 7,950
148 Chloramfecort Cream Tube 10 gram 13,400
149 Chloramfecort H Cream Tube 10 gram 11,500
150 KINA TABLET STRIP 12 TAB 14,800
151 TRINOLON 4 MG TABLET DUS 50 TABL 65,000

IV. PRODUK REGULER YANG TIDAK REPEAT PRODUKSI 2019 D

152 ASAM ASKORBAT (Vit C) TAB 100 MG BOTOL 100 11,040
153 ASAM ASKORBAT (Vit C) TAB 250 MG BOTOL 100 14,914
154 ASAM ASKORBAT (Vit C) TAB 50 MG BOTOL 100 11,440
155 Asam Mefenamat 500mg tabsalsel Dus 100 tabl 24,624
156 CALCIUM LACTATE TABLET BTL 100 TABL 8,582
157 CHLORAMPHENIKOL 250 MG KAPSUL BTL 100 KAPS 33,862
158 CHLOROQUINIE 150 MG BTL @100 TABL 15,273
159 CHLORPROMAZINE TAB SALUT 100 MG BOTOL 100 19,855
160 CODEIN TABLET 10 MG BOTOL 100 45,455
161 CODEIN TABLET 15 MG BOTOL 100 77,273
162 CODEIN TABLET 20 MG BOTOL 100 100,000
163 DEXAMETHASONE 0.5 MG BTL @100 TABL 10,909
164 EPHEDRINE 25 MG BTL @100 TABL 14,327
165 FUROSEMIDE 40 MG TABLET BOTOL 100 12,945
166 GLYCERIL GUAIACOLATE 100/300 MG BTL 100 TABL 8,364
167 HYDROCHLOROTHIAZIDE 25 MG BOTOL 100 10,909
168 ISONIAZID TABLET 100 MG BOTOL 100 23,527
169 ISONIAZIDE 300 MG BTL 100 TABL 14,738
170 PAPAVERIN TABLET 40 MG BOTOL 100 16,727
171 PARASETAMOL 500 MG TABL BTL 100 TABL 10,909
172 PHENOBARBITAL 30 MG BTL @100 TABL 12,000
173 PHERPENAZINE 4 MG BTL 100 TABL 6,986
174 PYRIDOXINE (Vit B6) TABLET 10 MG BOTOL 100 12,727
175 QUININE TABLET SALUT 222 MG BOTOL 100 61,818
176 RIFAMPICIN 300 MG KAPSUL DUS 100 KAPS 65,455
177 TETRASIKLIN KAPSUL 250 MG BOTOL 100 29,818
178 THIAMIN (Vitamin B1) TABLET 100 MG BOTOL 100 11,273
179 THIAMIN (Vitamin B1) TABLET 50 MG BOTOL 100 10,909
180 VITAMIN B KOMPLEKS BTL 100 TABL 9,455
181 VITAMIN B12 TABLET 50 MG BOTOL 100 6,909
182 Vitamin K 10 mg TSG (Generik) Dus 100 tabl 29,700
183 Vitamin K 10 mg/ml Injeksi Dus 100 ampul 184,183
184 TABLET TAMBAH DARAH SASE 30 TAB 2,000
185 ENKAPYRIN TABLET SALUT GULA BTL 250 KAPL 69,300
186 KETOKONAZOLE 2% KRIM TUBE 15 GRAM 6,873
187 Tablet Tambah Darah NEO Dus 10 strip @ 10 TSF 36,364
HNA + Ppn
2019

65,601
96,554
4,343
44,660
20,592
58,500
90,000
15,534
5,012
48,000
84,640
51,885
53,235
30,809
21,060
11,489
33,000
220,000
2,559
11,250
14,464
78,736
71,838
13,860
8,949
68,184
31,134
26,428
19,267
35,200
20,500
297,000
68,497
123,398
162,360
 27,421
6,655
11,745
13,591
20,490
14,278
66,020
17,200
22,385
97,126
13,721
91,846
83,752
24,000
8,984
220,003
26,664
3,651
23,910
38,004
71,664
97,724
130,299
23,488
51,699
3,848
12,800
6,534
7,205
19,877
59,967
14,256
19,030
22,399
28,083
5,610
5,198
57,684
220,889
27,549
15,897
27,060
14,300
12,650
20,020
 28,600
3,575
104,994
36,179
18,310
22,919
19,349
2,412
4,659
21,131
79,041
16,628
5,066
28,693
131,914
13,302
15,649
14,400
29,992
40,491
34,414
14,800
14,800
44,220
431,424
13,860
181,553
259,034
8,403
10,043
3,630
25,650
51,300
100,320
47,245
134,420
28,303
48,190
14,399
27,170
15,637
7,816
12,144
16,405
12,584 b., h ,i.jh.
 16,831 .u..u
47,500 ....

22,000
26,400
132,000
41,415
24,750
11,000
66,000
154,000
55,000
198,000

330,000
275,000

55,000
88,000

330,000

385,000

660,000

1,980,000

13,475
8,745
14,740
12,650
16,280
71,500
 DAFTAR HARGA OGB
PT. KIMIA FARMA 2019
PEMENANG EKATALOG GENERIK ( KF ) 2019

NO KODE SAP NAMA PRODUK KEMASAN

1 11000145 ALBENDAZOLE TABLET KUNYAH 400 DUS 10X10 TABL
2 11000291 ANTIHEMOROID SUPP 2G DUS 10 SUPP
3 11000016 Azithromycin 500 mg Kapsalsel Dus 20 kapl
4 11000383 BETAMETASON 0,1% KRIM TUBE 5 GRAM
5 11000161 CAPTOPRIL 12.5 MG DUS 10X10 TABL
6 11000170 CLONIDINE 0.15 MG. DUS 10X10 TABL
7 11000033 Codein 10 mg Tablet (strip) DUS 10X10 TABL
8 11000035 Codein 15 mg Tablet (Strip) DUS 10X10 TABL
9 11000037 Codein 20 mg Tablet (Strip) DUS 10X10 TABL
10 11000187 DILTIAZEM 30 MG DUS 10X10 TABL
11 11000188 DIMENHYDRINATE 50 MG BTL 100 TABL
12 11000060 Efavirens tablet salut selaput 600 mg Botol 30 tabl
13 11000192 ERGOTAMINE COFFEINE BTL 100 TABL
14 11000193 ETHAMBUTOL 250 MG. DUS 20X10 TABL
15 11000310 EUGENOL CAIRAN BTL 10 ML
16 11000233 Fenobarbital tablet 30 mg Dus 10 x 10 tablet
17 11000071 Fluconazole 150 mg Kapsul Dus 10 kaps
18 11000200 FUROSEMIDE 40 MG. DUS 20X10 TABL
19 11000076 Glimepiride 4 mg Tablet Dus 50 tabl
20 11000394 HIDROKORTISON ASETAT 2,5% KRIM TUBE 5 GRAM
21 11000204 HYDROCHLOROTHIAZIDE 25 MG DUS 10X10 TABL
22 11000395 KETOKONAZOLE 2% KRIM TUBE 10 GRAM
23 11000295 KLORAMFENIKOL SM 1% (STERIL) TUBE 5 GRAM
Kombinasi tab:
24 11000090 Btl 60 tabl
Zidovudin 300 mg + Lamivudin 150 mg
kombinasi: ferro fumarat 60 mg + as. Folat 0,4 mg tablet salut gula DUS 10X10 TABL
11000793
25 (tablet tambah darah)
26 11000088 Kombinasi: Sefiksim 400 mg + Azitromisin 1000 mg Paket
27 11000092 LAMIVUDINE 100 MG Btl 30 tabl
28 11000092 LAMIVUDINE 150 MG Btl 60 tabl
29 11000103 Metadon/Methadone hydrochloride/ Methadone sir 50 mg/mL Botol @ 1000 mL
30 11000222 METOCLOPRAMID 10 MG DUS 10X10 TABL
31 11000221 METOCLOPRAMIDE 5/100 MG-BLISTE DUS 10X10 TABL
32 11000296 MICONAZOLE KRIM 2% TUBE 10 GRAM
33 11000106 Morphine 10 mg Tablet Fles 30 tabl
34 11000111 Nevirapine 200 MG Btl 60 tabl
35 11000297 OKSITETRASIKLIN SM 1% TUBE 3,5 GRAM
36 11000229 ORALIT 200 ML DUS 100 SASE
NO KODE SAP NAMA PRODUK KEMASAN
37 11000248 PYRANTEL 125 MG. DUS 25X4 TABL
38 11000281 PYRIDOXINE (Vit B6) TABLET 10 MG DUS 10 x 10 tablet
39 11000253 QUININE 222 MG DUS 10X6 TABL
40 11000124 Rifampicin 450 mg Tabsalsel Dus 100 kapl
41 11000125 Rifampicin 600 mg Tabsalsel Dus 100 kapl
42 11000268 SULFADOXINE PYRIMETHAMINE DUS 10X10 TABL
43 11000521 Tenofovir Disoproxil Fumarate/ Tenofovir tab salut selaput 300 mg Botol @ 30 tablet salut sel
44 11000130 Tetracycline 500 mg Dus 100 kaps
45 11000277 Tiamin (Vitamin B1) tablet/kapsul/kaplet 50 mg DUS 10X10 TABL
46 11000274 VERAPAMIL 80 MG. DUS 10X10 TABL
47 11000487 VITAMIN B KOMPLEKS SUPLEMEN DUS 10X10 TABL
48 11000279 VITAMIN B12 0.05 MG DUS @ 10X10 TAB
49 11000288 VITAMIN C 50 SUPLEMEN DUS 10X10 TABL
50 11000143 Zidovudine 100 mg Kapsul Btl 60 kaps
 DAFTAR HARGA OGB
PT. KIMIA FARMA 2019

HNA EXCL HNA INCL

42,091 46,300
33,109 36,420
32,327 35,560
1,332 1,465
6,273 6,900
18,273 20,100
59,727 65,700
103,182 113,500
135,818 149,400
13,182 14,500
11,727 12,900
207,955 228,750
19,273 21,200
72,727 80,000
21,001 23,101
17,909 19,700
195,709 215,280
15,273 16,800
13,227 14,550
2,303 2,533
16,182 17,800
2,343 2,577
1,867 2,054
241,364 265,500

37,182 40,900
283,918 312,310
62,182 68,400
97,855 107,640
260,000 286,000
8,091 8,900
11,273 12,400
3,569 3,926
45,655 50,220
166,800 183,480
2,522 2,774
25,545 28,100
HNA EXCL HNA INCL
32,091 35,300
13,636 15,000
43,691 48,060
89,545 98,500
110,000 121,000
68,727 75,600
264,218 290,640
30,091 33,100
8,545 9,400
35,000 38,500
12,273 13,500
4,727 5,200
10,909 12,000
110,891 121,980
 DAFTAR HARGA OGB KIMIA FARMA 2019

1. BPJS GENERIK ( KF ) 2019

NO KODE SAP NAMA PRODUK KEMASAN HNA EXCL HNA INCL