1.

SATUAN KERJA ADALAH NAMA APOTEK, FKTP, FKRTL atau DINKES PROVINSI dan KAB/KOTA
2. JUMLAH KEBUTUHAN TAHUN 2021 ADALAH PEMAKAIAN RATA-RATA PER BULAN SELAMA 2019 DIKALI 18 BULAN DALAM SA
3. RENCANA KEBUTUHAN TAHUN 2021 ADALAH RENCANA KEBUTUHAN YANG DIHITUNG BERDASARKAN METODE KONSUMSI
4. RENCANA PENGADAAN TAHUN 2021 ADALAH RENCANA OBAT DALAM SATUAN TERKECIL SEPERTI: TABLET / KAPSUL / KAPL
5. SURAT PENGANTAR DAN LAMPIRAN HARUS DI TANDATANGANI OLEH KEPALA SATUAN KERJA DAN DIBERI STEMPEL
6. MOHON UNTUK TIDAK MELAKUKAN PENAMBAHAN MAUPUN PENGURANGAN BARIS/KOLOM PADA FORMAT

RENCANA KEBUTUHAN OBAT PADA FASILITAS KESEHATAN TINGKAT PERTAMA (FKTP

SATUAN KERJA :

NO NAMA OBAT SATUAN

1 Air untuk injeksi amp 20 ml ampul/vial/botol

2 Air untuk injeksi amp 25 ml ampul/vial/botol 2
3 Albendazol susp 200 mg/5 ml Botol
4 Albendazol tab 400 mg tablet/kapsul/kapl
5 Alopurinol tab 100 mg Tab
6 Alopurinol tab 300 mg tablet/kapsul/kapl
7 Aminofilin inj 24 mg/ml ampul/vial 10 ml
8 Aminofilin tab 150 mg tablet/kapsul/kapl
9 Aminofilin Tab 200 mg tablet/kapsul/kapl
10 Amitriptilin tab sal 25 mg tablet/kapsul/kapl
11 Amlodipin tab 10 mg tablet/kapsul/kapl
12 Amlodipin tab 5 mg tablet/kapsul/kapl
13 Amoksisilin drops 100 mg/ml Botol
14 Amoksisilin sir forte 250 mg/5 ml botol 60 ml
15 Amoksisilin sir kering 125 mg/5 ml Botol
16 Amoksisilin tab 250 mg tablet/kapsul/kapl
17 Amoksisilin tab 500 mg tablet/kapsul/kapl
18 Ampisilin serb inj 1000 mg/vial ampul/vial
19 Ampisilin serb inj 250 mg/vial Vial
20 Anestetik lokal gigi kombinasi : lidokain hcl 2% + epinefrin 1 : 80.000 inj 2 ampul/vial
ml
21 Antasida, kombinasi : aluminium hidroksida 200 mg + magnesium botol 60 ml
hidroksida 200 mg
22 Antasida, kombinasi : aluminium hidroksida 200 mg + magnesium tablet/kapsul/kapl
hidroksida 200 mg
23 Anti Parkinson kombinasi : benzerasid 25 mg + levodopa 100 mg Kaps
24 Antifungi salep, kombinasi : asam benzoat 6%+ asam salisilat 3% pot 30 g
25 Antihemoroid, kombinasi: bismut subgalat 150 mg + heksaklorofen 2,5 Suppositoria
mg + lidokain lidokain 10 mg+ seng oksida 120 mg + sup ad 2 g

26 Artesunat serb inj 60 mg/ml (i.v./i.m.) ampul/vial

27 Articulating paper kertas warna penanda oklusi Kertas warna penan
28 Asam asetat tetes telinga 2% Botol
29 Asam asetilsalisilat (asetosal) tab 80 mg tablet/kapsul/kapl
30 Asam askorbat (vitamin C) tab 250 mg Tab
31 Asam askorbat (vitamin C) tab 50 mg tablet/kapsul/kapl
32 Asam folat tab 0,4 mg tablet/kapsul/kapl
33 Asam folat tab 1 mg tablet/kapsul/kapl
34 Asam folat tab 5 mg Tab
35 Asam mefenamat kaps 250 mg tablet/kapsul/kapl
36 Asam mefenamat kaps 500 mg tablet/kapsul/kapl
37 Asam salisilat lar 0,1% Botol
38 Asam salisilat salep 10% Tube
39 Asam salisilat salep 2% Tube
40 Asam salisilat salep 5% Tube
41 Asiklovir tab 200 mg tablet/kapsul/kapl
42 Asiklovir tab 400 mg tablet/kapsul/kapl
43 Atapulgit 600 mg tablet/kapsul/kapl
44 Atapulgit tab 630 mg tablet/kapsul/kapl
45 Atapulgit tablet 650 mg tablet/kapsul/kapl
46 Atapulgit tablet 750 mg Tab
47 Atenolol tab 100 mg tablet/kapsul/kapl
48 Atenolol tab 50 mg tablet/kapsul/kapl
49 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) Ampul
50 Atropin tab 0,5 mg Tab
51 Bahan tumpatan sementara lar, serb Botol
52 Bedak salisil serb 2% Dus/Sachet/Plastik
53 Betametason krim 0,1% tube 5 gram
54 Betametason krim 0,5 mg/g Tube
55 Betametason salep 0,1% tube 5 gram
56 Betametason tts mata 1 mg/ml botol
57 Bisakodil sup 10 mg Suppositoria
58 Bisakodil sup 5 mg Suppositoria
59 Bisakodil tab sal 5 mg tablet/kapsul/kapl
60 Budesonid cairan ih 0,25mg/ml Botol @ 4 ml
61 Budesonid cairan ih 0,25mg/ml, respoules 2 ml respoules
62 Budesonid cairan ih 0,5 mg/ml Botol @ 4 ml
63 Budesonid cairan ih 0,5 mg/ml, respoules 2 ml respoules
 64 Budesonid serb ih 100 mcg/dosis Botol
65 Budesonid serb ih 200 mcg/dosis 100 dosis
66 Budesonid serb ih 200 mcg/dosis 200 dosis
67 Coal tar lar 5 % Botol
68 Copper T set/buah
69 Deksametason inj 5 mg/ml (i.v./i.m.) ampul/vial
70 Deksametason tab 0,5 mg tablet/kapsul/kapl
71 Diazepam enema 10 mg/2,5 ml tube @ 2,5 mL
72 Diazepam enema 5 mg/2,5 ml tube @ 2,5 mL
73 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
74 Diazepam tab 2 mg tablet/kapsul/kapl
75 Diazepam tab 5 mg tablet/kapsul/kapl
76 Dietilkarbamazin tab 100 mg tablet/kapsul/kapl
77 Difenhidramin inj 10 mg/ml (i.v./i.m.) ampul/vial
78 Digoksin tab 0,25 mg tablet/kapsul/kapl
79 Diltiazem hcl tab 30 mg tablet/kapsul/kapl
80 Diltiazem kaps SR 100 mg Kapsul lepas lamba
81 Diltiazem kaps SR 200 mg Kapsul lepas lamba
82 Diltiazem tab 30 mg Tab
83 Dimenhidrinat tab 50 mg tablet/kapsul/kapl
84 Doksisiklin kaps 100 mg tablet/kapsul/kapl
85 Domperidon susp 5 mg/5 ml botol @60 ml
86 Domperidon tab 10 mg tablet/kapsul/kapl
87 Epinefrin (adrenalin) inj 0,1% (i.v./s.k./i.m.) ampul/vial
88 Epinefrin (adrenalin) inj 1 mg/ml Ampul
89 Ergotamin tab 1 mg Tab
90 Eritromisin kaps 250 mg tablet/kapsul/kapl
91 Eritromisin sir 200 mg/5 ml Botol @ 60 ml
92 Eritromisin tab 500 mg tablet/kapsul/kapl
93 Estrogen terkonjugasi tab sal 0,625 mg tablet salut gula/ka
94 Etanol 70% cairan 70% Botol
95 Etil klorida semprot 100 ml Botol
96 Etonogestrel implan 68 mg Set
97 Eugenol Botol
98 Fenitoin Na inj 50 mg/ml ampul @ 2 ml
99 Fenitoin Na kaps 100 mg Kaps
100 Fenitoin Na kaps 30 mg Kaps
101 Fenobarbital tab 100 mg Tab
102 Fenobarbital tab 30 mg tablet/kapsul/kapl
103 Fenoksimetil penisilin (penisilin V) tab 250 mg Tab
104 Fenoksimetil penisilin (penisilin V) tab 500 mg Tab
105 Ferro fumarat kaps lunak 300 mg Kaps lunak
106 Ferro sulfat sir. 150 mg/5 ml Botol
107 Ferro sulfat tab salut 300 mg Tab sal
108 Fitomenadion (vitamin K 1) inj 2 mg/ml (i.m.) ampul/vial
109 Fitomenadion (vitamin K 1) tab sal 10 mg Tab sal
110 Fitomenadion (vitamin K1) inj 10 mg/ml (i.m) tablet salut gula/ka
111 Fluoksetin kaps 10 mg tablet/kapsul/kapl
112 Fluor kapl 1 mg Kaplet
113 Fluor sediaan topikal Tube
114 Fluoresein tts mata 2,5 mg/ml Botol
115 Formokresol Botol
116 Framisetin Sulfat Tulle 1% Patch
117 Furosemid inj 10 mg/ml (i.v./i.m.) ampul/vial
118 Furosemid tab 40 mg tablet/kapsul/kaple
119 Galactose microparticle 200-400 mg micropart/ml Vial
120 Garam oralit kombinasi : natrium klorida 0,52 g + kalium klorida 0,30 g + sachet
trinatrium sitrat 0,58 g + glukosa anhidrat 2,7 g
121 Gentamisin salep mata 0,3% Tube
122 Gentamisin tts mata 0,3% Botol
123 Glass ionomer ART (Atraumatic Restorative Treatment) cocoa butter 5 g Sachet

124 Glass ionomer ART (Atraumatic Restorative Treatment) lar Botol

125 Glass ionomer ART (Atraumatic Restorative Treatment) serb Vial
126 Glibenklamid tab 2,5 mg tablet/kapsul/kaple
127 Glibenklamid tab 5 mg tablet/kapsul/kaple
128 Glikuidon tab 30 mg tablet/kapsul/kaple
129 Glimepirid tab 1 mg tablet/kapsul/kaple
130 Glimepirid tab 2 mg tablet/kapsul/kaple
131 Glipizid tab 5 mg tablet/kapsul/kaple
132 Gliseril trinitrat tab 0,5 mg tablet/kapsul/kapl
133 Gliserin tts 100 mg/ml Botol
134 Glukosa Larutan Infus 10% steril 100 ml Botol
135 Glukosa Larutan Infus 10% steril 250 ml Botol
136 Glukosa Larutan Infus 10% steril 500 ml Botol
137 Glukosa Larutan Infus 40% Ampul @25 ml
138 Glukosa Larutan Infus 5% steril 100 ml Botol
139 Glukosa Larutan Infus 5% steril 250 ml Botol
140 Glukosa Larutan Infus 5% steril 500 ml Botol
141 Griseofulvin (micronized) tab 125 mg tablet/kapsul/kapl
142 Griseofulvin (micronized) tab scored 250 mg tablet/kapsul/kapl
143 Gutta percha dan paper points 15 - 40 mm Roll
144 Gutta percha dan paper points 45 - 80 mm Roll
145 Haloperidol inj 5 mg/ml (i.m.) Vial
146 Haloperidol tab 0,5 mg tablet/kapsul/kapl
147 Haloperidol tab 1,5 mg tablet/kapsul/kapl
148 Haloperidol tab 2 mg tablet/kapsul/kapl
149 Haloperidol tab 5 mg tablet/kapsul/kapl
150 Haloperidol tts 2 mg/ml botol
151 Hepatitis B imunoglobulin (human) inj 150 IU/1,5 ml Ampul
152 Hidrogen peroksida cairan 3% Botol
153 Hidrogen peroksida lar. Konsentrat 3% Botol
154 Hidroklorotiazid tab 25 mg tablet/kapsul/kapl
155 Hidrokortison krim 2,5% tube @ 5 g
156 Hidrokortison serb inj 100 mg Vial
157 Hiosina butilbromida tab 10 mg tablet/kapsul/kapl
158 Human tetanus imunoglobulin inj 250 UI (i.m.) Ampul
159 Human tetanus imunoglobulin inj 500 UI (i.m.) Ampul
160 Ibuprofen sir 100 mg/5 ml botol @ 60 ml
161 Ibuprofen sir 200 mg/5 ml botol @ 60 ml
162 Ibuprofen tab 200 mg tablet/kapsul/kapl
163 Ibuprofen tab 400 mg tablet/kapsul/kapl
164 Ipratropium bromida aerosol 20 mcg/semprot Botol
165 Ipratropium bromida cairan ih 0,025% Botol
166 Ipratropium bromida ih 20mcg/puff Botol
167 Isoniazid tab 100 mg Tab
168 Isoniazid tab 300 mg Tab
169 Isosorbid dinitrat tab 5 mg tablet/kapsul/kapl
170 IUD Cu T 380 A Set
171 IUD Levonorgestrel Set
172 Kalamin Tube
173 Kalsium glukonat inj 100 mg/ml ampul/vial
174 Kalsium hidroksida bubuk, pasta Tube
175 Kalsium karbonat tab 500 mg tablet/kapsul/kapl
176 Kalsium laktat (kalk) tab 500 mg tablet/kapsul/kapl
177 Kaptopril tab 12,5 mg tablet/kaplet
178 Kaptopril tab 25 mg tablet/kaplet
179 Kaptopril tab 50 mg tablet/kaplet
180 Karbamazepin sir 100 mg/5 ml Botol
181 Karbamazepin tab 100 mg Tab
182 Karbamazepin Tab 200 mg Tablet
183 Karbo adsorben tab 0,5 g Tab
184 Karbogliserin tts telinga 10 % Botol
185 Ketokonazol tab 200 mg tablet/kapsul/kapl
186 Klindamisin kaps 150 mg Kaps
187 Klindamisin kaps 300 mg tablet/kapsul/kapl
188 Klofazimin, micronized kaps 50 mg Kapsul
189 Klofazimin, micronizedkaps 100 mg kapsul
190 Klonidin tab 0,15 mg tablet/kapsul/kapl
191 Kloramfenikol kaps 250 mg tablet/kapsul/kapl
192 Kloramfenikol salep kulit 2% tube 15g
193 Kloramfenikol salep mata 1% tube @ 5 gram
194 Kloramfenikol susp 125 mg/5 ml botol 60 ml
195 Kloramfenikol tetes telinga 3% Botol
196 Kloramfenikol tts mata 0,5% botol
197 Kloramfenikol tts mata 1% Botol
198 Klorfeniramin tab 4 mg tablet/kapsul/kapl
199 Klorfenol kamfer mentol (CHKM) Botol
200 Klorheksidin lar 0,2% Botol
201 Klorheksidin lar 15% Botol
202 Klorpromazin inj 25 mg/ml (i.m.) ampul/vial
203 Klorpromazin inj 5 mg/ml (i.m.) ampul/vial
204 Klorpromazin tab sal 100 mg tablet salut selapu
205 Klorpromazin tab sal 25 mg Tab sal
206 Klortalidon tab 50 mg Tab
207 Klozapin tab 100 mg tablet
208 Klozapin tab 25 mg tablet
209 Kodein tab 10 mg tablet/kapsul/kapl
210 Kombinasi (DHP) : dihidroartemisin 40 mg + Piperakuin 320 mg tab sal tablet salut selapu
selaput
211 Kombinasi : artemether 20 mg + lumefantrin 120 mg tablet/kapsul/kapl
212 Kombinasi : artesunat tab 50 mg + amodiakuin tab 200 Tab
213 Kombinasi : Desogestrel 150 mcg Etinilestradiol 30 mcg Tab
214 Kombinasi : ergotamin 1 mg+ kafein 50 mg tablet/kapsul/kapl
215 Kombinasi : Ferro fumarat 60 mg + asam folat 0,4 mg tab salut tablet salut gula
216 Kombinasi : levonorgestrel 150 mcg + etinilestradiol 30 mcg tab salut gula
217 Kombinasi : Tenofovir 300 mg + Emtrisitabin 200 mg Tab
218 Kombinasi : Tenofovir 300 mg + Lamivudin 300 mg + Efavirenz 600 mg Tab

219 Kombinasi: ipratropium Br 0,5 mg+ salbutamol 2,5 mg nebules ampul/vial

220 Kombinasi: kaolin 550 mg + pektin 20 mg Tab
221 Komposit resin Set
222 Kotrimoksazol (dewasa) kombinasi : sulfametoksazol 400 mg+ tab/kaptab
trimetoprim 80 mg
223 Kotrimoksazol (dewasa) kombinasi : sulfametoksazol 800 mg+ tab/kaptab
trimetoprim 160 mg
224 Kotrimoksazol kombinasi tiap 5 ml suspensi : sulfametoksazol 200 mg + botol 60 mL
trimetoprim 40 mg
225 Kuinin inj 25% (i.v.) Vial
226 Kuinin tab 200 mg tablet/kapsul/kapl
227 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
228 Larutan mengandung Elektrolit (Kalium Klorida) Botol
229 Larutan mengandung Elektrolit (KCl 0,15%, NaCL 0,9%) (KN1) Botol
230 Larutan mengandung Elektrolit (KCl 0,3%,NaCl 0,9%) (KN2) Botol
231 Larutan mengandung Elektrolit (Na 130 mEq, K 4 mEq, Cl 109 mEq, Ca 3 Botol plastik @ 50
mEq, Asetat 28 mEq) Ringer Asetat
232 Larutan mengandung Elektrolit (Na 130 mEq, K 4 mEq, Cl 109 mEq, Ca 3 Softbag @ 500 ml
mEq, Asetat 28 mEq) Ringer Asetat
233 Larutan mengandung Elektrolit (NaCl 1.125 gr, Dekstrosa 18.75 gr) (KA EN Botol
1B)
234 Larutan mengandung Elektrolit (Sodium Lactate sol (50%) 113 gr/L, Botol
Potassium Chloride 0.3 gr/L, Calcium Chloride 0.2 gr/L, elektrolit)

235 Larutan mengandung Elektrolit (Tiap 1000 ml mengandung electrolit: Botol

Sodium 145 mmol/l, Potassium 4.0 mmol/l, Calcium 2.5 mmol/l,
Magnesium 1.0 mmol/l, Chloride 118 mmol/l, Acetate 24 mmol/l, Malate
5.0 mmol/l)

236 Larutan mengandung Karbohidrat (Fructose 120 g, glucose 66 g, Xylitol 60 Botol

g/ L)
237 Larutan mengandung Karbohidrat (Fructose 200 g, glucose 110 g, Xylitol Botol
100 g/ L)
238 Larutan mengandung Karbohidrat (Fructose 60 g, glucose 33 g, Xylitol 30 Botol
g/ L)
239 Larutan mengandung Karbohidrat (Maltose 10%) Botol
240 Larutan mengandung Karbohidrat + Elektrolit (25.00g maltose, 3.00 g Botol
sodium chloride, 0.15 g potassium chloride, 0.10 g calcium chloride
dihydrate dan 1.55 g sodium lactate)

241 Larutan mengandung Karbohidrat + Elektrolit (Acetate, Na, K, Cl, Ca, Mg, Botol
Sorbitol 50 gr/L)
242 Larutan mengandung Karbohidrat + Elektrolit (Dextrose 5%, NaCL 0,45%, Botol
KCl) (HSD)
243 Larutan mengandung Karbohidrat + Elektrolit (Fructose 120 g, glucose 66 Botol
g, Xylitol 60 g/ L + elektrolit)
244 Larutan mengandung Karbohidrat + Elektrolit (Glukosa 25 g, NaCl 2,0 g, Botol
KCl 1,3 g, Natrium Laktat 3,1 g, air untuk injeksi ad 1000 ml)
245 Larutan mengandung Karbohidrat + Elektrolit (Glukosa 55 g ; Natrium Botol
Chloride 9 g, air untuk injeksi ad 1000 ml) (D5-NS)
246 Larutan mengandung Karbohidrat + Elektrolit (Glukosa: 25,0 g; NaCl: 4,5 Botol
g)
247 Larutan mengandung Karbohidrat + Elektrolit (Glukosa: 55.0 g; NaCl: 2.25 Botol
g) (D5-1/4NS)
248 Larutan mengandung Karbohidrat + Elektrolit (Glukosa: 55.0 g; NaCl: 4.5 Botol
g) (D5-1/2NS)
249 Larutan mengandung Karbohidrat + Elektrolit (Larutan nutrisi kombinasi Botol
infus per L: Na. 100mEQ, K 18mEQ, Ca. 4mEQ, Mg 6mEQ, Cl 90mEQ,
Asetat 38mEQ, Sorbitol 50g)

250 Larutan mengandung Karbohidrat + Elektrolit (Larutan Ringer & Glukosa Botol
5%)
251 Larutan mengandung Karbohidrat + Elektrolit (NaCl 1.75 g, KCL 1.5g, Botol
Glukosa 100 gr)
252 Larutan mengandung Karbohidrat + Elektrolit (NaCl 1.75 g, KCL 1.5g, Na Botol
Lactate 2.24 g, Glukosa 100 gr)
253 Larutan mengandung Karbohidrat + Elektrolit (Nacl 1.75 gr, KCl 1.5 gr, Na Botol
Lactat 2.24 gr, Dekstrosa 27 gr) (KA EN 3B)
254 Larutan mengandung Karbohidrat + Elektrolit (Nacl 2.34 gr, Na Laktat Botol
2.24 gr, KCL 0.75 gr Dekstrosa 27 gr) (KA EN 3A)
255 Levonorgestrel implan 2 rods, 75 mg (3-4 tahun) pack/ sachet/ set
256 Lidokain gel 2% syringe/syringe pla
257 Lidokain inj 2% (infiltr/p.v.) ampul/vial
258 Lidokain spray oral 10% botol
259 Linestrenol tab 0,5 mg tablet/kapsul/kapl
260 Loperamid tab 2 mg Tab
261 Loratadin tab 10 mg tablet/kapsul/kapl
262 Lorazepam tab 0,5 mg tablet/kapsul/kapl
263 Lorazepam tab 1 mg tablet/kapsul/kapl
264 Lorazepam tab sal 2 mg Tab sal
265 Lugol Botol
266 Magnesium sulfat inj 20% ampul/vial
267 Magnesium sulfat inj 20% ampul/vial @25 ml
268 Magnesium sulfat inj 40% ampul/vial
269 Magnesium sulfat inj 40% ampul/vial @25 ml
270 Magnesium sulfat serb, ktg 30 g Sachet
271 Mebendazol sir 100 mg/5 ml Botol
272 Mebendazol tab 100 mg Tan
273 Mebendazol tab 500 mg tablet/kapsul/kapl
274 Medroksi progesteron asetat inj 150 mg/ml ampul/vial
275 Medroksi Progesteron Asetat Inj 50 mg/ml ampul/vial
276 Metenamin mandelat (heksamin mandelat) tab salut enterik 500 mg Tab salut

277 Metformin tab 500 mg tablet/kapsul/kapl

278 Metformin tab 850 mg tablet/kapsul/kapl
279 Metilergometrin inj 0,2 mg/ml ampul/vial
280 Metilergometrin tab salut 0,125 mg tablet/kaplet salut
281 Metilprednisolon tab 4 mg tablet/kapsul/kapl
282 Metoklopramid inj 5 mg/ml ampul/vial
283 Metoklopramid tab 10 mg tablet/kapsul/kapl
284 Metoklopramid tab 5 mg tablet/kapsul/kapl
285 Metronidazol lar inf 5 mg/ml botol
286 Metronidazol susp 125 mg/5 ml Botol @ 60 ml
287 Metronidazol susp 125 mg/5 ml Botol @ 100 ml
288 Metronidazol tab 250 mg tablet/kapsul/kapl
289 Metronidazol tab 500 mg tablet/kapsul/kapl
290 Mikonazol krim 2% tube
291 Mikonazol serb 2% botol / sachet
292 Mineral Mix (Bismuth Subcitrate Tripotasium, Copper sulfate, Magnesium Sachet
Chloride Anhydrous, Potassium Chloride, Zinc Acetate)

293 N-asetil sistein kaps 200 mg tablet/kapsul/kapl

294 NaCl 0,9% Larutan Botol plastik/botol
295 NaCl 0,9% Larutan Botol
296 NaCl 0,9% Larutan ampul/botol plasti
297 Natrium diklofenak tab 25 mg tablet salut enteri
298 Natrium diklofenak tab 50 mg tablet salut enteri
299 Natrium Diklofenak Tetes Mata 1 mg/ml botol 5 mL
300 Natrium hipoklorit cairan konsentrat 5% Botol
301 Natrium tiosulfat inj 25% (i.v.) Ampul
302 Nifedipin kaps 10 mg tablet/kapsul/kapl
303 Nikotinamid tab 100 mg Tab
304 Nikotinamid tab 5 mg Tab
305 Nistatin susp 100.000 UI/ml botol/vial
306 Nistatin tab salut 500.000 UI tablet salut gula/ka
307 Nistatin tab vaginal 100.000 UI tablet/kaplet
308 Nitrofurantoin tab 50 mg Tab
309 Norepinefrin inj 1 mg/ml ampul/vial
310 Obat Anti Tuberculosis FDC Kategori Anak paket
311 Obat Anti Tuberculosis FDC Kategori I paket
312 Obat Anti Tuberculosis FDC Kategori II paket
313 Obat Anti Tuberculosis FDC Kategori Sisipan paket
314 Obat Anti Tuberculosis Kombipak Anak Paket
315 Obat Anti Tuberculosis Kombipak Dewasa paket
316 Oksigen ih, gas dlm tabung Botol
317 Oksimetazolin tts hidung 0,025% botol @ 10 mL
318 Oksimetazolin tts hidung 0,050% botol @ 10 mL
319 Oksitetrasiklin 1% Salep Mata tube
320 Oksitosin inj 10 UI/ml ampul/vial
321 Olopatadin tts mata 0,1% Botol
322 Omeprazol inj 40 mg/10 ml ampul/vial
323 Omeprazol kaps 20 mg tablet/kapsul/kapl
324 Paraformaldehid tab 1 g Tab
325 Parasetamol sir 120 mg/5 ml botol @ 60 mL
326 Parasetamol tab 500 mg tablet/kapsul/kapl
327 Parasetamol tts 60 mg/0,6 ml botol @ 15 mL
328 Pasta devitalisasi (non arsen) Tube
329 Pasta pengisi saluran akar (pasta) Tube
330 Perak nitrat lar 20% Botol
331 Perak sulfadiazin krim 1% Tube
332 Permetrin krim 5 % Tube
333 Pirantel pamoat susp 125 mg/5 ml Botol
334 Pirantel pamoat tab 500 mg Tab
335 Pirantel pamoat tab scored 125 mg tablet/kapsul/kapl
336 Pirantel pamoat tab scored 250 mg Tab
337 Piridoksin (vitamin B6) inj 100 mg/ml Ampul
338 Piridoksin (vitamin B6) tab 10 mg tab/kap/kapl
339 Piridoksin (vitamin B6) tab 25 mg tablet/kapsul/kapl
340 Povidon iodin lar 100 mg/ml botol 30 mL
341 Povidon iodin lar 100 mg/ml botol @ 60 mL
342 Povidon iodin lar 100 mg/ml Botol 300 ml
343 Povidon iodin lar 100 mg/ml botol @ 1.000 mL
344 Prednison tab 5 mg tablet/kapsul/kapl
345 Primakuin tab 15 mg Tab
346 Probenesid tab 500 mg tablet/kapsul/kapl
347 Prokain benzilpenisilin serb inj 3 juta UI/vial (i.m.) ampul/vial
348 Propiltiourasil tab 100 mg tablet/kapsul/kapl
349 Propranolol tab 10 mg tablet/kapsul/kapl
350 Ranitidin tab 150 mg tablet/kapsul/kapl
351 Retinol (vitamin A) kaps lunak 100.000 UI kaps lunak
352 Retinol (vitamin A) kaps lunak 200.000 UI kaps lunak
353 Rifampisin kaps 300 mg tablet/kapsul/kapl
354 Ringer Laktat Larutan Botol
355 Risperidon tab sal 1 mg tablet/kapsul/kapl
356 Risperidon tab sal 2 mg tablet/kapsul/kapl
357 Salbutamol cairan ih 0,1% ampul/vial/botol
358 Salbutamol lar ih 0,5 % Botol
359 Salbutamol sir 2 mg/5 ml Botol
360 Salbutamol tab 2 mg tablet/kapsul/kapl
361 Salbutamol tab 4 mg tablet/kapsul/kapl
362 Salep 2-4, kombinasi : asam salisilat 2 %+ belerang endap 4 % pot 30 gram
363 Salep 2-4, kombinasi : asam salisilat 2 %+ belerang endap 4 % pot 15 gram
364 Serum anti bisa ular : A.B.U. I (khusus ular dari luar Papua) inj (i.m./i.v.) Vial

365 Serum anti bisa ular :A.B.U.II (khusus ular dari Papua) inj (i.m./i.v.) Vial

366 Serum antidifteri (A.D.S) inj (i.m./i.v.) Inj i.m 10.000 UI/ Vial
367 Serum antirabies inj 100 UI/ml Vial
368 Serum antirabies inj 200 UI/ml Vial
369 Serum antitetanus (A.T.S) (i.m.) Inj 10.000 UI/vial (i.m /i.v.) Vial
370 Serum antitetanus (A.T.S) inj 1500 UI/amp (i.m.) Ampul
371 Serum antitetanus (A.T.S) inj 20.000 UI/vial (i.m /i.v.) Vial
372 Setirizin sir 5 mg/5 ml. botol @ 60 mL
373 Sianokobalamin (vitamin B12) inj 500 mcg/ml ampul/vial
374 Sianokobalamin (vitamin B12) tab 50 mcg tablet/kapsul/kapl
375 Simvastatin tab sal 10 mg tablet/kapsul/kaple
376 Simvastatin tab sal 20 mg tablet/kapsul/kaple
377 Simvastatin tab sal selaput 40 mg Tab sal
378 Siprofloksasin tab scored 500 mg tablet salut selapu
379 Siprofloksasin tetes mata 3 mg/ml Catchcover, botol
380 Spironolakton tab 25 mg tablet/kapsul/kapl
381 Stannous pyrophosphate 27,6 mg sodium pyrophosphate/vial Vial
382 Streptomisin serb inj 1.000 mg/vial ampul/vial
383 Surgical ginggival pack Tube
384 Tenofovir tab 300 mg tablet salut selapu
385 Tetanus toxoid inj Ampul
386 Tetrakain tts mata 0,5% Botol
387 Tetrasiklin kaps 250 mg tablet/kapsul/kapl
388 Tetrasiklin kaps 500 mg tablet/kapsul/kapl
389 Tetrasiklin Salep Mata 1% Tube
390 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/kapl
391 Timolol tts mata 0,25% botol @ 5 mL
392 Timolol tts mata 0,5% botol @ 5 mL
393 Triheksifenidil tab 2 mg tablet/kapsul/kapl
394 Urea krim 10 % pot
395 Vaksin BCG inj (i.k) Vial
396 Vaksin bivalen OPV (b-OPV) drops 10 dosis Vial
397 Vaksin Hepatitis Rekombinan Inj Prefilled Injection Device (Uniject) 0,5 ml Vial
(i.m)
398 Vaksin Influenza Vial
399 Vaksin Japanese Enchepalitis (J.E) Vial
400 Vaksin jerap difteri tetanus (DT) Vial
401 Vaksin jerap difteri tetanus (Td) Vial
402 Vaksin kombinasi DPT-HB-Hib Vial
403 Vaksin measless rubella (MR) Inj 0,5 mL (s.k) Vial
404 Vaksin Meningitis Meningokokus Vial
405 Vaksin polio IPV inj 0,5 ml Vial
406 Vaksin rabies, untuk manusia serb inj (s.k./i.k) + booster Vial
407 Vaksin rabies, untuk manusia serb Inj 2,5 IU Vial
408 Vaksin Yellow Fever Vial
409 Valproat sir 250 mg/5 ml botol @ 120 ml
410 Valproat tab sal 250 mg tablet salut enterik
411 Valproat tab sal 500 mg Tab sal
412 Vitamin B kompleks tablet
413 Zinc drops 10 mg/ml Botol
414 Zinc serb 10 mg Sachet
415 Zinc sir 10 mg/ml Botol
416 Zinc sir 20 mg/5 ml botol
417 Zinc tab disp 20 mg tablet dispersible
AMA 2019 DIKALI 18 BULAN DALAM SATUAN TERKECIL SEPERTI : TABLET / KAPSUL / KAPLET / BOTOL / AMPUL / VIAL / TUBE / SACCHET / P
G BERDASARKAN METODE KONSUMSI DIKURANGI DENGAN SISA STOK PER 31 DESEMBER 2019
ECIL SEPERTI: TABLET / KAPSUL / KAPLET / BOTOL / AMPUL / VIAL / TUBE / SACCHET / PUFF YANG AKAN DIADAKAN TAHUN 2021 BERDASA
N KERJA DAN DIBERI STEMPEL
/KOLOM PADA FORMAT

TINGKAT PERTAMA (FKTP) TAHUN 2021

SISA STOK PER 31 PEMAKAIAN JUMLAH RENCANA RENCANA RENCANA

DESEMBER 2019 RATA-RATA PER KEBUTUHAN KEBUTUHAN PENGADAAN PENGADAAN
BULAN SELAMA TAHUN 2021 TAHUN 2021 TAHUN 2021 TAHUN 2020
2019

(a) (b) (c) = (b) x 18 (d) = (c) - (a) (e) (f)

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VIAL / TUBE / SACCHET / PUFF

AN TAHUN 2021 BERDASARKAN PERKIRAAN ANGGARAN YANG DIPEROLEH TAHUN 2021

REALISASI KETERANGAN
PENGADAAN
TAHUN 2019

(g) (h)
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