NO PROVINSI

1 LAMPUNG 2211
BANTEN & DKI JAKARTA 2214
BANTEN & DKI JAKARTA 2215
2 BANTEN & DKI JAKARTA 2101
BANTEN & DKI JAKARTA 2212
BANTEN & DKI JAKARTA 2213
JAWA BARAT 2216
JAWA BARAT 2217
3 JAWA BARAT 2218
JAWA BARAT 2219
JAWA BARAT 2220
JAWA TENGAH & DIY 2221
JAWA TENGAH & DIY 2222
4 JAWA TENGAH & DIY 2223
JAWA TENGAH & DIY 2224
JAWA TENGAH & DIY 2225
JAWA TIMUR 2226
JAWA TIMUR 2227
5 JAWA TIMUR 2228
JAWA TIMUR 2230
JAWA TIMUR 2229
6 BALI 2231
7 KEPULAUAN BANGKA BELITUNG 2209
8 NUSA TENGGARA BARAT 2232
9 SULAWESI UTARA 2239
10 SULAWESI TENGAH 2241
11 NUSA TENGGARA TIMUR 2233
12 MALUKU 2244
13 MALUKU UTARA 2245
14 PAPUA BARAT 2246
15 PAPUA 2247
SUMATERA UTARA 2202
16
SUMATERA UTARA 2203
17 SUMATERA BARAT 2204
18 RIAU 2205
19 JAMBI 2207
20 SUMATERA SELATAN 2208
21 BENGKULU 2210
22 NANGGROE ACEH DARUSSALAM 2201
23 KALIMANTAN BARAT 2234
24 KEPULAUAN RIAU 2206
25 KALIMANTAN SELATAN 2236
KAL-TIMUR & KAL-UTARA 2237
26
KAL-TIMUR & KAL-UTARA 2238
27 SULAWESI TENGGARA 2242
28 GORONTALO 2243
29 SULAWESI SELATAN & SUL-BARAT 2240
30 KALIMANTAN TENGAH 2235
KENAIKAN HARGA OBAT E-KATALOG TAHUN 2019

KODE
No Nama Generik Kemasan
MATERIAL

Antimalaria kapsul/kaplet/tablet, kombinasi:

1 11000268 Dus, 10 strip @10 tablet
Sulfadoksin 500 mg + Pirimetamin 25 mg

Betametason/Betamethasone Valerate krim

2 11000383 Tube @ 5 gram
0,1%
Chloramphenicol/ Kloramfenikol salep mata 1
3 11000295 % Tube @ 5 gram

Cyanocobalamin/ Cyanocobalamine/
4 11000279 Sianokobalamin (vitamin B12) Dus, 10 strip @10 tablet
tablet/kapsul/kaplet 50 mcg
Diltiazem/ Diltiazem HCl tablet/kapsul/kaplet
5 11000187 30 mg Dus, 10 strip @ 10 tablet

6 11000188 Dimenhidrinat tablet/kapsul/kaplet 50 mg botol plastik @ 100 tablet

Etambutol/ Ethambutol tablet/kapsul/kaplet Dus, 20 strip @10 tablet

7 11000193 250 mg salut selaput
Etambutol/ Ethambutol tablet/kapsul/kaplet Dus, 10 strip @10 tablet
8 11000194
500 mg salut selaput

9 11000200 Furosemid/ Furosemide tablet/kapsul/kaplet Dus, 20 strip @10 tablet

40 mg

Garam Oralit I serbuk, kombinasi: Natrium

10 11000229 klorida 0,52 g + kalium klorida 0,30 g + Dus, 100 sachet
Trinatrium sitrat dihidrat 0,58 g + Glukosa
Anhidrat 2,70 g
11 11000073 Glimepiride tablet/kapsul/kaplet 1 mg Dus, 5 strip @10 tablet
12 11000074 Glimepiride tablet/kapsul/kaplet 2 mg Dus, 5 strip @10 tablet
13 11000075 Glimepiride tablet/kapsul/kaplet 3 mg Dus, 5 strip @10 tablet
14 11000076 Glimepiride tablet/kapsul/kaplet 4 mg Dus, 5 strip @10 tablet
15 11000161 Kaptopril/ Captopril tablet/kaplet 12,5 mg Dus, 10 strip @10 tablet
kombinasi: ergotamin 1 mg + kafein 50 mg botol plastik @ 100 tablet
16 11000192 (tablet)
salut selaput
Levofloxacin hemihydrate/
Dus, 5 strip @10 tablet
17 11000217 Levofloxacin/Levofloksasin salut selaput
tablet/kapsul/kaplet salut selaput 500 mg

Methylergometrine Maleate/
18 11000104 Methylergometrine/ Metilergometrin Dus, 10 strip @10 tablet
tablet/kaplet salut selaput 0,125 mg
 Metoclopramide hydrochloride (HCl)/
19 11000222 Metoclopramide/ Metoklopramid Dus, 10 strip @10 tablet
tablet/kapsul/kaplet 10 mg

20 11000227 Nifedipine/ Nifedipin tablet/kapsul/kaplet 10 Dus, 10 strip @10 tablet

mg
21 11000117 Obat Anti Tuberculosis FDC Kategori Anak Paket
22 11000118 Obat Anti Tuberculosis FDC Kategori I Paket
23 11000297 Oksitetrasiklin 1% salep mata Tube @ 3,5 gram

24 11000248 Pirantel pamoat/ Pyrantel Pamoate Dus, 25 catchcover @ 1

tablet/kapsul/kaplet 125 mg strip @ 4 tablet
Botol plastik @ 50 kapsul
25 11000309 Retinol (vitamin A) kapsul lunak 100.000 IU
lunak
Retinol acetate/ Retinol (vitamin A) kaps lunak
26 11000304 200.000 IU botol plastik @ 50 kapsul

Rifampicin/ Rifampisin tablet/kapsul/kaplet Dus, 10 strip @ 10 kaptab

27 11000124 450 mg salut selaput
Rifampicin/ Rifampisin tablet/kapsul/kaplet Dus, 10 strip @ 10 kaptab
28 11000125 600 mg
salut selaput
Salbutamol sulfate/ Salbutamol
29 11000259 tablet/kapsul/kaplet 2 mg Dus, 10 strip @10 tablet

Tetrasiklin/ Tetracycline/ Tetracycline

30 11000130 Dus, 10 strip @10 kapsul
Hydrochloride tablet/kapsul/kaplet 500 mg

31 11000275 Tiamin (Vitamin B1) tablet/kapsul/kaplet 50 mg Dus, 10 strip @10 tablet

32 11000274 Verapamil hydrochloride (HCL)/ Verapamil Dus, 10 strip @10 tablet

tablet/kapsul/kaplet 80 mg salut selaput
33 11000310 Eugenol cairan Botol 10 ml

34 11000486 Pyridoxine/ Piridoksin (Vitamin B6)

tab/kap/kapl 10 mg (HCl) Dus, 10 strip @ 10 tablet
 PAPUA
HNA Excl Ppn

74,727

1,475

2,095

14,818

12,727

81,636

17,091

28,727

8,636
10,455
12,818
13,227
7,182

20,909

25,636
 9,000

-
-
2,522

17,500

99,909

123,182

33,727

38,091

22,826

14,909
I. KATEGORI OBAT LELANG PELAYANAN BPJS -REGULER (Non ID PAKET)
PAPUA
NO KODE KODE 2 NAMA OBAT KEMASAN UOM KET
HARGA
Albendazol tablet/kapsul/kaplet 400
1 11000145 Dus, 10 strip @10 tablet kunyah Dus TDK NAIK HARGA 45,818
mg
Amlodipin/Amlodipine/Amlodipine
2 11000151 Besylate/Amlodipine Besilate Dus, 5 strip @10 tablet Dus TDK NAIK HARGA 4,500
tablet/kapsul/kaplet 10 mg
Amlodipin/Amlodipine/Amlodipine
3 11000150 Besylate/Amlodipine Besilate Dus, 5 strip @10 tablet Dus TDK NAIK HARGA 3,773
tablet/kapsul/kaplet 5 mg
Azitromisin/Azithromycin dihydrate
4 11000016 tablet/kapsul/kaplet salut selaput 500 Dus, 2 strip @10 kaptab salut selaput Dus TDK NAIK HARGA 32,327
mg
Clonidinehydrochloride/ Clonidine/
5 11000170 Dus, 10 strip @10 tablet Dus TDK NAIK HARGA
Klonidin tablet/kapsul/kaplet 0,15 mg
CODEINE PHOSPHATE HEMIHYDRATE/
6 11000033 Codeine/ Kodein tablet/kapsul/kaplet Dus, 10 strip @ 10 tablet Dus TDK NAIK HARGA 62,273
10 mg
CODEINE PHOSPHATE HEMIHYDRATE/
7 11000035 Codeine/ Kodein tablet/kapsul/kaplet Dus, 10 strip @ 10 tablet Dus TDK NAIK HARGA 112,182
15 mg
CODEINE PHOSPHATE HEMIHYDRATE/
8 11000037 Codeine/ Kodein tablet/kapsul/kaplet Dus, 10 strip @ 10 tablet Dus TDK NAIK HARGA 147,636
20 mg
Dietilkarbamazin/ Diethylcarbamazine
9 11000185 Dus, 10 strip @10 tablet Dus TDK NAIK HARGA
tablet 100 mg
Fenobarbital/ Phenobarbital
10 11000233 Dus, 10 strip @ 10 tablet Dus TDK NAIK HARGA 19,455
tablet/kapsul/kaplet 30 mg
Hidrokortison/ Hydrocortisone krim 2,5
11 11000394 Dus, 24 tube @ 5 gram Tube TDK NAIK HARGA 2,587
%
12 11000395 Ketokonazol/ Ketoconazole krim 2% Dus,tube 10 gr Tube TDK NAIK HARGA 2,630
kombinasi: ferro fumarat 60 mg + as.
13 11000793 Folat 0,4 mg tablet salut gula (tablet Dus, 10 strip @ 10 tablet salut gula Dus TDK NAIK HARGA
tambah darah)
Metoclopramide hydrochloride (HCl)/
14 11000221 Metoclopramide/ Metoklopramid Dus, 10 strip @10 tablet Dus TDK NAIK HARGA 12,636
tablet/kapsul/kaplet 5 mg
Miconazole nitrate/ Miconazole/
15 11000296 Dus, 24 tube @ 10 gr Tube TDK NAIK HARGA 3,880
Mikonazol krim 2 %
Salbutamol sulfate/ Salbutamol
16 11000262 Dus, 10 strip @10 tablet Dus TDK NAIK HARGA
tablet/kapsul/kaplet 4 mg
17 11000487 11000399 Vitamin B Kompleks tablet Dus, 10 strip @ 10 tablet Dus TDK NAIK HARGA
I. KATEGORI OBAT LELANG PELAYANAN BPJS -REGULER (Non ID PAKET)
PAPUA
NO KODE KODE 2 NAMA OBAT KEMASAN UOM KET
HARGA
Zinc sulfate/ Zinc sulfate
18 11000144 monohydrate/Zinc/ Zinc tablet Dus, 10 strip @10 tablet dispersibel Dus TDK NAIK HARGA
dispersible 20 mg
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)

KODE
LAMPUNG DKI & BANTEN BANTEN DKI JAKARTA
NO KODE 1 NAMA GENERIK KEMASAN UOM KET
TAMBAHAN
HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST

Antihemoroid, kombinasi sup :

bismut subgalat
HARGA TIDAK
1 11000291 heksaklorofen Dus, 10 supp Dus 28,791 6.50% 28,791 6.50% 28,791 6.50% 28,791 6.50%
NAIK
lidokain
seng oksida
HARGA TIDAK
2 11000288 11000287 Asam askorbat (vitamin C) tab 50 mg Dus, 10 strip @ 10 tablet Dus 9,524 10.00% 9,524 10.00% 9,524 10.00% 9,524 10.00%
NAIK
Dus, botol plastik @ 30 tablet HARGA TIDAK
3 11000060 Efavirens tablet salut selaput 600 mg Botol 180,818 13.00% 180,818 13.00% 180,818 13.00% 180,818 13.00%
salut selaput NAIK
HARGA TIDAK
4 11000071 Flukonazol/ Fluconazole tab/kaps 150 mg (G) Dus, 1 strip @ 10 kapsul Dus 170,182 13.00% 170,182 13.00% 170,182 13.00% 170,182 13.00%
NAIK
HARGA TIDAK
5 11000204 Hidroklorotiazid/ Hydrochlorothiazide tab 25 mg Dus, 10 strip @ 10 tablet Dus 14,091 10.00% 14,091 10.00% 14,091 10.00% 14,091 10.00%
NAIK
Kombinasi tab: HARGA TIDAK
6 11000090 Dus, botol plastik @ 60 kaptab Botol 209,891 13.00% 209,891 13.00% 209,891 13.00% 209,891 13.00%
Zidovudin 300 mg + Lamivudin 150 mg NAIK
Kombinasi: Sefiksim 400 mg + Azitromisin 1000 Paket/Amp HARGA TIDAK
7 11000088 Dus, 10 samplop @ 2 strip 28,392 13.00% 28,392 13.00% 28,392 13.00% 28,392 13.00%
mg lop NAIK
HARGA TIDAK
8 11000091 Lamivudine/ Lamivudin tab 100 mg (G) Dus, botol @ 30 tablet Botol 62,182 10.00% 62,182 10.00% 62,182 10.00% 62,182 10.00%
NAIK
HARGA TIDAK
9 11000092 Lamivudine/ Lamivudine tablet 150 mg (G) Dus, botol @ 60 tablet Botol 85,091 13.00% 85,091 13.00% 85,091 13.00% 85,091 13.00%
NAIK
Metadon/Methadone hydrochloride/ Methadone HARGA TIDAK
10 11000103 Botol @ 1000 mL Botol 260,000 10.00% 260,000 10.00% 260,000 10.00% 260,000 10.00%
sir 50 mg/mL NAIK
Morphine hydrochloride(HCl)/ Morphine/ Morfin HARGA TIDAK
11 11000106 Botol @ 30 tablet Botol 39,709 13.00% 39,709 13.00% 39,709 13.00% 39,709 13.00%
tablet 10 mg (G) NAIK
Nevirapine/ Nevirapin tablet/kapsul/kaplet 200 HARGA TIDAK
12 11000111 Dus, botol plastik @ 60 kaptab Botol 166,800 13.00% 166,800 13.00% 166,800 13.00% 166,800 13.00%
mg NAIK
Quinine/ Quinine sulfate/ Kuinin tab 200 mg (222 Dus, 10 strip @ 6 tablet salut HARGA TIDAK
13 11000253 Dus 38,018 10.00% 38,018 10.00% 38,018 10.00% 38,018 10.00%
mg sebagai garam) selaput NAIK
Tenofovir Disoproxil Fumarate/ Tenofovir tab Dus, botol plastik @ 30 tablet HARGA TIDAK
14 11000521 Botol 229,745 13.00% 229,745 13.00% 229,745 13.00% 229,745 13.00%
salut selaput 300 mg salut selaput NAIK
HARGA TIDAK
15 11000143 Zidovudine/ Zidofudin kapsul 100 mg Dus, botol plastik @ 60 kapsul Botol 96,436 13.00% 96,436 13.00% 96,436 13.00% 96,436 13.00%
NAIK
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)
JAWA TENGAH &
KODE
JAWA BARAT DIY
JAWA TENGAH DI YOGYAKARTA JAWA TIMUR BALI
NO KODE 1 NAMA GENERIK KEMASAN
TAMBAHAN
HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA

Antihemoroid, kombinasi sup :

bismut subgalat
1 11000291 heksaklorofen Dus, 10 supp 28,791 6.50% 28,791 6.50% 28,791 6.50% 28,791 6.50% 28,791 6.50% 28,791
lidokain
seng oksida

2 11000288 11000287 Asam askorbat (vitamin C) tab 50 mg Dus, 10 strip @ 10 tablet 9,524 10.00% 9,524 10.00% 9,524 10.00% 9,524 10.00% 9,524 10.00% 9,524
Dus, botol plastik @ 30 tablet
3 11000060 Efavirens tablet salut selaput 600 mg 180,818 13.00% 180,818 13.00% 180,818 13.00% 180,818 13.00% 180,818 13.00% 180,818
salut selaput
4 11000071 Flukonazol/ Fluconazole tab/kaps 150 mg (G) Dus, 1 strip @ 10 kapsul 170,182 13.00% 170,182 13.00% 170,182 13.00% 170,182 13.00% 170,182 13.00% 170,182

5 11000204 Hidroklorotiazid/ Hydrochlorothiazide tab 25 mg Dus, 10 strip @ 10 tablet 14,091 10.00% 14,091 10.00% 14,091 10.00% 14,091 10.00% 14,091 10.00% 14,091
Kombinasi tab:
6 11000090 Dus, botol plastik @ 60 kaptab 209,891 13.00% 209,891 13.00% 209,891 13.00% 209,891 13.00% 209,891 13.00% 209,891
Zidovudin 300 mg + Lamivudin 150 mg
Kombinasi: Sefiksim 400 mg + Azitromisin 1000
7 11000088 Dus, 10 samplop @ 2 strip 28,392 13.00% 28,392 13.00% 28,392 13.00% 28,392 13.00% 28,392 13.00% 28,392
mg
8 11000091 Lamivudine/ Lamivudin tab 100 mg (G) Dus, botol @ 30 tablet 62,182 10.00% 62,182 10.00% 62,182 10.00% 62,182 10.00% 62,182 10.00% 62,182

9 11000092 Lamivudine/ Lamivudine tablet 150 mg (G) Dus, botol @ 60 tablet 85,091 13.00% 85,091 13.00% 85,091 13.00% 85,091 13.00% 85,091 13.00% 85,091
Metadon/Methadone hydrochloride/ Methadone
10 11000103 Botol @ 1000 mL 260,000 10.00% 260,000 10.00% 260,000 10.00% 260,000 10.00% 260,000 10.00% 260,000
sir 50 mg/mL
Morphine hydrochloride(HCl)/ Morphine/ Morfin
11 11000106 Botol @ 30 tablet 39,709 13.00% 39,709 13.00% 39,709 13.00% 39,709 13.00% 39,709 13.00% 39,709
tablet 10 mg (G)
Nevirapine/ Nevirapin tablet/kapsul/kaplet 200
12 11000111 Dus, botol plastik @ 60 kaptab 166,800 13.00% 166,800 13.00% 166,800 13.00% 166,800 13.00% 166,800 13.00% 166,800
mg
Quinine/ Quinine sulfate/ Kuinin tab 200 mg (222 Dus, 10 strip @ 6 tablet salut
13 11000253 38,018 10.00% 38,018 10.00% 38,018 10.00% 38,018 10.00% 38,018 10.00% 38,018
mg sebagai garam) selaput
Tenofovir Disoproxil Fumarate/ Tenofovir tab Dus, botol plastik @ 30 tablet
14 11000521 229,745 13.00% 229,745 13.00% 229,745 13.00% 229,745 13.00% 229,745 13.00% 229,745
salut selaput 300 mg salut selaput
15 11000143 Zidovudine/ Zidofudin kapsul 100 mg Dus, botol plastik @ 60 kapsul 96,436 13.00% 96,436 13.00% 96,436 13.00% 96,436 13.00% 96,436 13.00% 96,436
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)
SUMATERA
BALI SUMATERA UTARA SUMATERA BARAT RIAU JAMBI
NO KODE 1
KODE
NAMA GENERIK KEMASAN SELATAN
TAMBAHAN
FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST

Antihemoroid, kombinasi sup :

bismut subgalat
1 11000291 heksaklorofen Dus, 10 supp 6.50% 30,227 6.50% 30,227 6.50% 30,227 6.50% 30,227 6.50% 30,227 6.50%
lidokain
seng oksida

2 11000288 11000287 Asam askorbat (vitamin C) tab 50 mg Dus, 10 strip @ 10 tablet 10.00% 9,965 10.00% 9,965 10.00% 9,965 10.00% 9,965 10.00% 9,965 10.00%
Dus, botol plastik @ 30 tablet
3 11000060 Efavirens tablet salut selaput 600 mg 13.00% 189,873 13.00% 189,873 13.00% 189,873 13.00% 189,873 13.00% 189,873 13.00%
salut selaput
4 11000071 Flukonazol/ Fluconazole tab/kaps 150 mg (G) Dus, 1 strip @ 10 kapsul 13.00% 178,691 13.00% 178,691 13.00% 178,691 13.00% 178,691 13.00% 178,691 13.00%

5 11000204 Hidroklorotiazid/ Hydrochlorothiazide tab 25 mg Dus, 10 strip @ 10 tablet 10.00% 14,818 10.00% 14,818 10.00% 14,818 10.00% 14,818 10.00% 14,818 10.00%
Kombinasi tab:
6 11000090 Dus, botol plastik @ 60 kaptab 13.00% 220,364 13.00% 220,364 13.00% 220,364 13.00% 220,364 13.00% 220,364 13.00%
Zidovudin 300 mg + Lamivudin 150 mg
Kombinasi: Sefiksim 400 mg + Azitromisin 1000
7 11000088 Dus, 10 samplop @ 2 strip 13.00% 28,392 13.00% 28,392 13.00% 28,392 13.00% 28,392 13.00% 28,392 13.00%
mg
8 11000091 Lamivudine/ Lamivudin tab 100 mg (G) Dus, botol @ 30 tablet 10.00% 62,182 10.00% 62,182 10.00% 62,182 10.00% 62,182 10.00% 62,182 10.00%

9 11000092 Lamivudine/ Lamivudine tablet 150 mg (G) Dus, botol @ 60 tablet 13.00% 89,345 13.00% 89,345 13.00% 89,345 13.00% 89,345 13.00% 89,345 13.00%
Metadon/Methadone hydrochloride/ Methadone
10 11000103 Botol @ 1000 mL 10.00% 260,000 10.00% 260,000 10.00% 260,000 10.00% 260,000 10.00% 260,000 10.00%
sir 50 mg/mL
Morphine hydrochloride(HCl)/ Morphine/ Morfin
11 11000106 Botol @ 30 tablet 13.00% 41,700 13.00% 41,700 13.00% 41,700 13.00% 41,700 13.00% 41,700 13.00%
tablet 10 mg (G)
Nevirapine/ Nevirapin tablet/kapsul/kaplet 200
12 11000111 Dus, botol plastik @ 60 kaptab 13.00% 166,800 13.00% 166,800 13.00% 166,800 13.00% 166,800 13.00% 166,800 13.00%
mg
Quinine/ Quinine sulfate/ Kuinin tab 200 mg (222 Dus, 10 strip @ 6 tablet salut
13 11000253 10.00% 39,927 10.00% 39,927 10.00% 39,927 10.00% 39,927 10.00% 39,927 10.00%
mg sebagai garam) selaput
Tenofovir Disoproxil Fumarate/ Tenofovir tab Dus, botol plastik @ 30 tablet
14 11000521 13.00% 241,227 13.00% 241,227 13.00% 241,227 13.00% 241,227 13.00% 241,227 13.00%
salut selaput 300 mg salut selaput
15 11000143 Zidovudine/ Zidofudin kapsul 100 mg Dus, botol plastik @ 60 kapsul 13.00% 101,236 13.00% 101,236 13.00% 101,236 13.00% 101,236 13.00% 101,236 13.00%
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)
KEPULAUAN NUSA TENGGARA
BENGKULU KEPULAUAN RIAU ACEH KALIMANTAN BARAT
NO KODE 1
KODE
NAMA GENERIK KEMASAN BANGKA BELITUNG BARAT
TAMBAHAN
HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA

Antihemoroid, kombinasi sup :

bismut subgalat
1 11000291 heksaklorofen Dus, 10 supp 30,227 6.50% 30,227 8.00% 30,227 8.00% 33,109 8.00% 33,109 8.00% 33,109
lidokain
seng oksida

2 11000288 11000287 Asam askorbat (vitamin C) tab 50 mg Dus, 10 strip @ 10 tablet 9,965 10.00% 9,965 11.00% 9,965 11.00% 10,935 11.00% 10,935 11.00% 10,935
Dus, botol plastik @ 30 tablet
3 11000060 Efavirens tablet salut selaput 600 mg 189,873 13.00% 189,873 13.50% 189,873 13.50% 207,955 13.50% 207,955 13.50% 207,955
salut selaput
4 11000071 Flukonazol/ Fluconazole tab/kaps 150 mg (G) Dus, 1 strip @ 10 kapsul 178,691 13.00% 178,691 13.50% 178,691 13.50% 195,709 13.50% 195,709 13.50% 195,709

5 11000204 Hidroklorotiazid/ Hydrochlorothiazide tab 25 mg Dus, 10 strip @ 10 tablet 14,818 10.00% 14,818 11.00% 14,818 11.00% 16,182 11.00% 16,182 11.00% 16,182
Kombinasi tab:
6 11000090 Dus, botol plastik @ 60 kaptab 220,364 13.00% 220,364 13.50% 220,364 13.50% 241,364 13.50% 241,364 13.50% 241,364
Zidovudin 300 mg + Lamivudin 150 mg
Kombinasi: Sefiksim 400 mg + Azitromisin 1000
7 11000088 Dus, 10 samplop @ 2 strip 28,392 13.00% 28,392 13.50% 28,392 13.50% 28,392 13.50% 28,392 13.50% 28,392
mg
8 11000091 Lamivudine/ Lamivudin tab 100 mg (G) Dus, botol @ 30 tablet 62,182 10.00% 62,182 11.00% 62,182 11.00% 62,182 11.00% 62,182 11.00% 62,182

9 11000092 Lamivudine/ Lamivudine tablet 150 mg (G) Dus, botol @ 60 tablet 89,345 13.00% 89,345 13.50% 89,345 13.50% 97,855 13.50% 97,855 13.50% 97,855
Metadon/Methadone hydrochloride/ Methadone
10 11000103 Botol @ 1000 mL 260,000 10.00% 260,000 11.00% 260,000 11.00% 260,000 11.00% 260,000 11.00% 260,000
sir 50 mg/mL
Morphine hydrochloride(HCl)/ Morphine/ Morfin
11 11000106 Botol @ 30 tablet 41,700 13.00% 41,700 13.50% 41,700 13.50% 45,655 13.50% 45,655 13.50% 45,655
tablet 10 mg (G)
Nevirapine/ Nevirapin tablet/kapsul/kaplet 200
12 11000111 Dus, botol plastik @ 60 kaptab 166,800 13.00% 166,800 13.50% 166,800 13.50% 166,800 13.50% 166,800 13.50% 166,800
mg
Quinine/ Quinine sulfate/ Kuinin tab 200 mg (222 Dus, 10 strip @ 6 tablet salut
13 11000253 39,927 10.00% 39,927 11.00% 39,927 11.00% 43,691 11.00% 43,691 11.00% 43,691
mg sebagai garam) selaput
Tenofovir Disoproxil Fumarate/ Tenofovir tab Dus, botol plastik @ 30 tablet
14 11000521 241,227 13.00% 241,227 13.50% 241,227 13.50% 264,218 13.50% 264,218 13.50% 264,218
salut selaput 300 mg salut selaput
15 11000143 Zidovudine/ Zidofudin kapsul 100 mg Dus, botol plastik @ 60 kapsul 101,236 13.00% 101,236 13.50% 101,236 13.50% 110,891 13.50% 110,891 13.50% 110,891
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)
KALIMANTAN KALIMANTAN KALIMANTAN TIMUR
KALIMANTAN BARAT SULAWESI UTARA SULAWESI TENGAH
NO KODE 1
KODE
NAMA GENERIK KEMASAN SELATAN TENGAH & UTARA
TAMBAHAN
FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST

Antihemoroid, kombinasi sup :

bismut subgalat
1 11000291 heksaklorofen Dus, 10 supp 8.00% 33,109 8.00% 34,545 10.00% 33,109 8.00% 33,109 10.00% 33,109 10.00%
lidokain
seng oksida

2 11000288 11000287 Asam askorbat (vitamin C) tab 50 mg Dus, 10 strip @ 10 tablet 11.00% 10,935 11.00% 11,464 12.00% 10,935 11.00% 10,935 12.00% 10,935 12.00%
Dus, botol plastik @ 30 tablet
3 11000060 Efavirens tablet salut selaput 600 mg 13.50% 207,955 13.50% 216,982 15.50% 207,955 13.50% 207,955 15.50% 207,955 15.50%
salut selaput
4 11000071 Flukonazol/ Fluconazole tab/kaps 150 mg (G) Dus, 1 strip @ 10 kapsul 13.50% 195,709 13.50% 204,218 15.50% 195,709 13.50% 195,709 15.50% 195,709 15.50%

5 11000204 Hidroklorotiazid/ Hydrochlorothiazide tab 25 mg Dus, 10 strip @ 10 tablet 11.00% 16,182 11.00% 16,909 12.00% 16,182 11.00% 16,182 12.00% 16,182 12.00%
Kombinasi tab:
6 11000090 Dus, botol plastik @ 60 kaptab 13.50% 241,364 13.50% 251,891 15.50% 241,364 13.50% 241,364 15.50% 241,364 15.50%
Zidovudin 300 mg + Lamivudin 150 mg
Kombinasi: Sefiksim 400 mg + Azitromisin 1000
7 11000088 Dus, 10 samplop @ 2 strip 13.50% 28,392 13.50% 28,392 15.50% 28,392 13.50% 28,392 15.50% 28,392 15.50%
mg
8 11000091 Lamivudine/ Lamivudin tab 100 mg (G) Dus, botol @ 30 tablet 11.00% 62,182 11.00% 62,182 12.00% 62,182 11.00% 62,182 12.00% 62,182 12.00%

9 11000092 Lamivudine/ Lamivudine tablet 150 mg (G) Dus, botol @ 60 tablet 13.50% 97,855 13.50% 102,109 15.50% 97,855 13.50% 97,855 15.50% 97,855 15.50%
Metadon/Methadone hydrochloride/ Methadone
10 11000103 Botol @ 1000 mL 11.00% 260,000 11.00% 260,000 12.00% 260,000 11.00% 260,000 12.00% 260,000 12.00%
sir 50 mg/mL
Morphine hydrochloride(HCl)/ Morphine/ Morfin
11 11000106 Botol @ 30 tablet 13.50% 45,655 13.50% 47,645 15.50% 45,655 13.50% 45,655 15.50% 45,655 15.50%
tablet 10 mg (G)
Nevirapine/ Nevirapin tablet/kapsul/kaplet 200
12 11000111 Dus, botol plastik @ 60 kaptab 13.50% 166,800 13.50% 166,800 15.50% 166,800 13.50% 166,800 15.50% 166,800 15.50%
mg
Quinine/ Quinine sulfate/ Kuinin tab 200 mg (222 Dus, 10 strip @ 6 tablet salut
13 11000253 11.00% 43,691 11.00% 45,600 12.00% 43,691 11.00% 43,691 12.00% 43,691 12.00%
mg sebagai garam) selaput
Tenofovir Disoproxil Fumarate/ Tenofovir tab Dus, botol plastik @ 30 tablet
14 11000521 13.50% 264,218 13.50% 275,700 15.50% 264,218 13.50% 264,218 15.50% 264,218 15.50%
salut selaput 300 mg salut selaput
15 11000143 Zidovudine/ Zidofudin kapsul 100 mg Dus, botol plastik @ 60 kapsul 13.50% 110,891 13.50% 115,745 15.50% 110,891 13.50% 110,891 15.50% 110,891 15.50%
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)
SULAWESI SELATAN SULAWESI NUSA TENGGARA
GORONTALO MALUKU MALUKU UTARA
NO KODE 1
KODE
NAMA GENERIK KEMASAN & BARAT TENGGARA TIMUR
TAMBAHAN
HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA

Antihemoroid, kombinasi sup :

bismut subgalat
1 11000291 heksaklorofen Dus, 10 supp 33,109 10.00% 34,545 10.00% 34,545 10.00% 35,991 12.50% 35,991 12.50% 35,991
lidokain
seng oksida

2 11000288 11000287 Asam askorbat (vitamin C) tab 50 mg Dus, 10 strip @ 10 tablet 10,935 12.00% 11,464 12.00% 11,464 12.00% 11,905 13.00% 11,905 13.00% 11,905
Dus, botol plastik @ 30 tablet
3 11000060 Efavirens tablet salut selaput 600 mg 207,955 15.50% 216,982 15.50% 216,982 15.50% 226,036 16.50% 226,036 16.50% 226,036
salut selaput
4 11000071 Flukonazol/ Fluconazole tab/kaps 150 mg (G) Dus, 1 strip @ 10 kapsul 195,709 15.50% 204,218 15.50% 204,218 15.50% 212,727 16.50% 212,727 16.50% 212,727

5 11000204 Hidroklorotiazid/ Hydrochlorothiazide tab 25 mg Dus, 10 strip @ 10 tablet 16,182 12.00% 16,909 12.00% 16,909 12.00% 17,636 13.00% 17,636 13.00% 17,636
Kombinasi tab:
6 11000090 Dus, botol plastik @ 60 kaptab 241,364 15.50% 251,891 15.50% 251,891 15.50% 262,364 16.50% 262,364 16.50% 262,364
Zidovudin 300 mg + Lamivudin 150 mg
Kombinasi: Sefiksim 400 mg + Azitromisin 1000
7 11000088 Dus, 10 samplop @ 2 strip 28,392 15.50% 28,392 15.50% 28,392 15.50% 28,392 16.50% 28,392 16.50% 28,392
mg
8 11000091 Lamivudine/ Lamivudin tab 100 mg (G) Dus, botol @ 30 tablet 62,182 12.00% 62,182 12.00% 62,182 12.00% 62,182 13.00% 62,182 13.00% 62,182

9 11000092 Lamivudine/ Lamivudine tablet 150 mg (G) Dus, botol @ 60 tablet 97,855 15.50% 102,109 15.50% 102,109 15.50% 106,364 16.50% 106,364 16.50% 106,364
Metadon/Methadone hydrochloride/ Methadone
10 11000103 Botol @ 1000 mL 260,000 12.00% 260,000 12.00% 260,000 12.00% 260,000 13.00% 260,000 13.00% 260,000
sir 50 mg/mL
Morphine hydrochloride(HCl)/ Morphine/ Morfin
11 11000106 Botol @ 30 tablet 45,655 15.50% 47,645 15.50% 47,645 15.50% 49,636 16.50% 49,636 16.50% 49,636
tablet 10 mg (G)
Nevirapine/ Nevirapin tablet/kapsul/kaplet 200
12 11000111 Dus, botol plastik @ 60 kaptab 166,800 15.50% 166,800 15.50% 166,800 15.50% 166,800 16.50% 166,800 16.50% 166,800
mg
Quinine/ Quinine sulfate/ Kuinin tab 200 mg (222 Dus, 10 strip @ 6 tablet salut
13 11000253 43,691 12.00% 45,600 12.00% 45,600 12.00% 47,509 13.00% 47,509 13.00% 47,509
mg sebagai garam) selaput
Tenofovir Disoproxil Fumarate/ Tenofovir tab Dus, botol plastik @ 30 tablet
14 11000521 264,218 15.50% 275,700 15.50% 275,700 15.50% 287,182 16.50% 287,182 16.50% 287,182
salut selaput 300 mg salut selaput
15 11000143 Zidovudine/ Zidofudin kapsul 100 mg Dus, botol plastik @ 60 kapsul 110,891 15.50% 115,745 15.50% 115,745 15.50% 120,545 16.50% 120,545 16.50% 120,545
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)

KODE
MALUKU UTARA PAPUA BARAT PAPUA
NO KODE 1 NAMA GENERIK KEMASAN
TAMBAHAN
FEE DIST HARGA FEE DIST HARGA FEE DIST

Antihemoroid, kombinasi sup :

bismut subgalat
1 11000291 heksaklorofen Dus, 10 supp 12.50% 35,991 12.50% 35,991 12.50%
lidokain
seng oksida

2 11000288 11000287 Asam askorbat (vitamin C) tab 50 mg Dus, 10 strip @ 10 tablet 13.00% 11,905 13.00% 11,905 13.00%
Dus, botol plastik @ 30 tablet
3 11000060 Efavirens tablet salut selaput 600 mg 16.50% 226,036 16.50% 226,036 16.50%
salut selaput
4 11000071 Flukonazol/ Fluconazole tab/kaps 150 mg (G) Dus, 1 strip @ 10 kapsul 16.50% 212,727 16.50% 212,727 16.50%

5 11000204 Hidroklorotiazid/ Hydrochlorothiazide tab 25 mg Dus, 10 strip @ 10 tablet 13.00% 17,636 13.00% 17,636 13.00%
Kombinasi tab:
6 11000090 Dus, botol plastik @ 60 kaptab 16.50% 262,364 16.50% 262,364 16.50%
Zidovudin 300 mg + Lamivudin 150 mg
Kombinasi: Sefiksim 400 mg + Azitromisin 1000
7 11000088 Dus, 10 samplop @ 2 strip 16.50% 28,392 16.50% 28,392 16.50%
mg
8 11000091 Lamivudine/ Lamivudin tab 100 mg (G) Dus, botol @ 30 tablet 13.00% 62,182 13.00% 62,182 13.00%

9 11000092 Lamivudine/ Lamivudine tablet 150 mg (G) Dus, botol @ 60 tablet 16.50% 106,364 16.50% 106,364 16.50%
Metadon/Methadone hydrochloride/ Methadone
10 11000103 Botol @ 1000 mL 13.00% 260,000 13.00% 260,000 13.00%
sir 50 mg/mL
Morphine hydrochloride(HCl)/ Morphine/ Morfin
11 11000106 Botol @ 30 tablet 16.50% 49,636 16.50% 49,636 16.50%
tablet 10 mg (G)
Nevirapine/ Nevirapin tablet/kapsul/kaplet 200
12 11000111 Dus, botol plastik @ 60 kaptab 16.50% 166,800 16.50% 166,800 16.50%
mg
Quinine/ Quinine sulfate/ Kuinin tab 200 mg (222 Dus, 10 strip @ 6 tablet salut
13 11000253 13.00% 47,509 13.00% 47,509 13.00%
mg sebagai garam) selaput
Tenofovir Disoproxil Fumarate/ Tenofovir tab Dus, botol plastik @ 30 tablet
14 11000521 16.50% 287,182 16.50% 287,182 16.50%
salut selaput 300 mg salut selaput
15 11000143 Zidovudine/ Zidofudin kapsul 100 mg Dus, botol plastik @ 60 kapsul 16.50% 120,545 16.50% 120,545 16.50%
I. KATEGORI OBAT LELANG PELAYANAN BPJS -REGULER (Non ID PAKET)
ADJUST LAMPUNG BANTEN
NO KODE NAMA OBAT KEMASAN UOM NAIK HARGA
HNA MIN HNA MAX FEE DIST HJP HARGA FEE DIST HARGA
Dus, 10 strip @10 tablet
1 11000145 Albendazol tablet/kapsul/kaplet 400 mg Dus #N/A 36,545 0 10.00% 32,891 36,545 10.00%
kunyah
Amlodipin/Amlodipine/Amlodipine
2 11000151 Besylate/Amlodipine Besilate tablet/kapsul/kaplet Dus, 5 strip @10 tablet Dus #N/A 4,500 8.00% 4,140
10 mg
Amlodipin/Amlodipine/Amlodipine
3 11000150 Besylate/Amlodipine Besilate tablet/kapsul/kaplet 5 Dus, 5 strip @10 tablet Dus #N/A 3,773 7.00% 3,509
mg
Azitromisin/Azithromycin dihydrate Dus, 2 strip @10 kaptab
5 11000016 Dus #N/A 32,327 4.00% 31,034 32,327 4.00% 32,327
tablet/kapsul/kaplet salut selaput 500 mg salut selaput
Clonidinehydrochloride/ Clonidine/ Klonidin
8 11000170 Dus, 10 strip @10 tablet Dus #N/A 15,818 10.00% 14,236 15,818 10.00%
tablet/kapsul/kaplet 0,15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
9 11000033 Dus, 10 strip @ 10 tablet Dus #N/A 51,909 13.00% 45,161 51,909 13.00% 51,909
Kodein tablet/kapsul/kaplet 10 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
10 11000035 Dus, 10 strip @ 10 tablet Dus #N/A 89,727 13.00% 78,063 89,727 13.00% 89,727
Kodein tablet/kapsul/kaplet 15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
11 11000037 Dus, 10 strip @ 10 tablet Dus #N/A 118,091 13.00% 102,739 118,091 13.00% 118,091
Kodein tablet/kapsul/kaplet 20 mg
Dietilkarbamazin/ Diethylcarbamazine tablet 100
13 11000185 Dus, 10 strip @10 tablet Dus #N/A 14,182 13.00% 12,338
mg
Fenobarbital/ Phenobarbital tablet/kapsul/kaplet
18 11000233 Dus, 10 strip @ 10 tablet Dus #N/A 15,545 10.00% 13,991 15,545 10.00% 15,545
30 mg
25 11000394 Hidrokortison/ Hydrocortisone krim 2,5 % Dus, 24 tube @ 5 gram Tube #N/A 2,250 4.00% 2,160 2,250 4.00% 2,250
27 11000395 Ketokonazol/ Ketoconazole krim 2% Dus,tube 10 gr Tube #N/A 2,289 5.00% 2,175 2,289 5.00% 2,289
kombinasi: ferro fumarat 60 mg + as. Folat 0,4 mg Dus, 10 strip @ 10 tablet
29 11000793 Dus #N/A 32,182 13.00% 27,998
tablet salut gula (tablet tambah darah) salut gula
Metoclopramide hydrochloride (HCl)/
33 11000221 Metoclopramide/ Metoklopramid Dus, 10 strip @10 tablet Dus #N/A 11,000 13.00% 9,570 11,000 13.00% 11,000
tablet/kapsul/kaplet 5 mg
Miconazole nitrate/ Miconazole/ Mikonazol krim 2
34 11000296 Dus, 24 tube @ 10 gr Tube #N/A 3,104 13.00% 2,700 3,104 13.00% 3,104
%
Salbutamol sulfate/ Salbutamol
45 11000262 Dus, 10 strip @10 tablet Dus #N/A 7,182 5.00% 6,823
tablet/kapsul/kaplet 4 mg
49 11000487 Vitamin B Kompleks tablet Dus, 10 strip @ 10 tablet Dus #N/A 10,636 10.00% 9,573 10,636 10.00% 10,727
Zinc sulfate/ Zinc sulfate monohydrate/Zinc/ Zinc Dus, 10 strip @10 tablet
50 11000144 Dus #N/A 47,636 13.00% 41,444 47,636 13.00%
tablet dispersible 20 mg dispersibel
I. KATEGORI OBAT LELANG PELAYANAN BPJS -REGULER (Non ID PAKET) F
DI E
BANTEN DKI JAKARTA JAWA BARAT JAWA TENGAH YOGYAKA E JAWA TIMUR BALI
NO KODE NAMA OBAT KEMASAN RTA
FEE
HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA HARGA FEE DIST HARGA
DIST D
Dus, 10 strip @10 tablet I
1 11000145 Albendazol tablet/kapsul/kaplet 400 mg 36,545 10.00% 36,636
kunyah S
Amlodipin/Amlodipine/Amlodipine T
2 11000151 Besylate/Amlodipine Besilate tablet/kapsul/kaplet Dus, 5 strip @10 tablet
10 mg
Amlodipin/Amlodipine/Amlodipine
3 11000150 Besylate/Amlodipine Besilate tablet/kapsul/kaplet 5 Dus, 5 strip @10 tablet
mg
Azitromisin/Azithromycin dihydrate Dus, 2 strip @10 kaptab
5 11000016 4.00% 32,327 4.00% 32,327 4.00% 32,327 4.00% 32,327
### 32,327 4.00% 32,327
tablet/kapsul/kaplet salut selaput 500 mg salut selaput
Clonidinehydrochloride/ Clonidine/ Klonidin
8 11000170 Dus, 10 strip @10 tablet 15,818 10.00% 15,818 10.00% 15,818
tablet/kapsul/kaplet 0,15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
9 11000033 Dus, 10 strip @ 10 tablet 13.00% 51,909 13.00% 51,909 13.00% 51,909 13.00% 51,909
### 51,909 13.00% 51,909
Kodein tablet/kapsul/kaplet 10 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
10 11000035 Dus, 10 strip @ 10 tablet 13.00% 89,727 13.00% 89,727 13.00% 89,727 13.00% 89,727
### 89,727 13.00% 89,727
Kodein tablet/kapsul/kaplet 15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
11 11000037 Dus, 10 strip @ 10 tablet 13.00% 118,091 13.00% 118,091 13.00% 118,091 13.00% 118,091
### 118,091 13.00% 118,091
Kodein tablet/kapsul/kaplet 20 mg
Dietilkarbamazin/ Diethylcarbamazine tablet 100
13 11000185 Dus, 10 strip @10 tablet 14,182 13.00% 14,182 13.00% 14,182
mg
Fenobarbital/ Phenobarbital tablet/kapsul/kaplet
18 11000233 Dus, 10 strip @ 10 tablet 10.00% 15,545 10.00% 15,545 10.00% 15,545 10.00% 15,545
### 15,545 10.00% 15,545
30 mg
25 11000394 Hidrokortison/ Hydrocortisone krim 2,5 % Dus, 24 tube @ 5 gram 4.00% 2,250 4.00% 2,250 4.00% 2,250 4.00% 2,250
### 2,250 4.00% 2,250
27 11000395 Ketokonazol/ Ketoconazole krim 2% Dus,tube 10 gr 5.00% 2,289 5.00% 2,289 5.00% 2,289 5.00% 2,289
### 2,289 5.00% 2,289
kombinasi: ferro fumarat 60 mg + as. Folat 0,4 mg Dus, 10 strip @ 10 tablet
29 11000793 32,182 13.00% 32,182 13.00% 32,182
tablet salut gula (tablet tambah darah) salut gula
Metoclopramide hydrochloride (HCl)/
33 11000221 Metoclopramide/ Metoklopramid Dus, 10 strip @10 tablet 13.00% 11,000 13.00% 11,000 13.00% 11,000 13.00% 11,000
### 11,000 13.00% 11,000
tablet/kapsul/kaplet 5 mg
Miconazole nitrate/ Miconazole/ Mikonazol krim 2
34 11000296 Dus, 24 tube @ 10 gr 13.00% 3,104 13.00% 3,104 13.00% 3,104 13.00% 3,104
### 3,104 13.00% 3,104
%
Salbutamol sulfate/ Salbutamol
45 11000262 Dus, 10 strip @10 tablet
tablet/kapsul/kaplet 4 mg
49 11000487 Vitamin B Kompleks tablet Dus, 10 strip @ 10 tablet 10.00% 10,636 10.00% 10,727
Zinc sulfate/ Zinc sulfate monohydrate/Zinc/ Zinc Dus, 10 strip @10 tablet
50 11000144 47,636 13.00% 47,636
###
tablet dispersible 20 mg dispersibel
I. KATEGORI OBAT LELANG PELAYANAN BPJS -REGULER (Non ID PAKET)
BALI SUMATERA UTARA SUMATERA BARAT RIAU JAMBI SUMATERA SELATAN
NO KODE NAMA OBAT KEMASAN
FEE
FEE DIST HARGA FEE DIST HARGA HARGA FEE DIST HARGA FEE DIST HARGA
DIST
Dus, 10 strip @10 tablet
1 11000145 Albendazol tablet/kapsul/kaplet 400 mg 10.00% 38,455 10.00% 38,364 10.00% 38,364 10.00%
kunyah
Amlodipin/Amlodipine/Amlodipine
2 11000151 Besylate/Amlodipine Besilate tablet/kapsul/kaplet Dus, 5 strip @10 tablet
10 mg
Amlodipin/Amlodipine/Amlodipine
3 11000150 Besylate/Amlodipine Besilate tablet/kapsul/kaplet 5 Dus, 5 strip @10 tablet
mg
Azitromisin/Azithromycin dihydrate Dus, 2 strip @10 kaptab
5 11000016 4.00% 32,327 4.00% 32,327 4.00% 32,327 4.00% 32,327 4.00% 32,327
tablet/kapsul/kaplet salut selaput 500 mg salut selaput
Clonidinehydrochloride/ Clonidine/ Klonidin
8 11000170 Dus, 10 strip @10 tablet 10.00% 16,636 10.00% 16,636
tablet/kapsul/kaplet 0,15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
9 11000033 Dus, 10 strip @ 10 tablet 13.00% 54,545 13.00% 54,545 13.00% 54,545 13.00% 54,545 13.00% 54,545
Kodein tablet/kapsul/kaplet 10 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
10 11000035 Dus, 10 strip @ 10 tablet 13.00% 94,182 13.00% 94,182 13.00% 94,182 13.00% 94,182 13.00% 94,182
Kodein tablet/kapsul/kaplet 15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
11 11000037 Dus, 10 strip @ 10 tablet 13.00% 124,000 13.00% 124,000 13.00% 124,000 13.00% 124,000 13.00% 124,000
Kodein tablet/kapsul/kaplet 20 mg
Dietilkarbamazin/ Diethylcarbamazine tablet 100
13 11000185 Dus, 10 strip @10 tablet 13.00% 14,909 13.00% 14,909 13.00% 14,909
mg
Fenobarbital/ Phenobarbital tablet/kapsul/kaplet
18 11000233 Dus, 10 strip @ 10 tablet 10.00% 16,364 10.00% 16,364 10.00% 16,364 10.00% 16,364 10.00% 16,364
30 mg
25 11000394 Hidrokortison/ Hydrocortisone krim 2,5 % Dus, 24 tube @ 5 gram 4.00% 2,250 4.00% 2,250 4.00% 2,250 4.00% 2,250 4.00% 2,250
27 11000395 Ketokonazol/ Ketoconazole krim 2% Dus,tube 10 gr 5.00% 2,289 5.00% 2,289 5.00% 2,289 5.00% 2,289 5.00% 2,289
kombinasi: ferro fumarat 60 mg + as. Folat 0,4 mg Dus, 10 strip @ 10 tablet
29 11000793 13.00% 33,818 13.00% 33,818 13.00%
tablet salut gula (tablet tambah darah) salut gula
Metoclopramide hydrochloride (HCl)/
33 11000221 Metoclopramide/ Metoklopramid Dus, 10 strip @10 tablet 13.00% 11,000 13.00% 11,000 13.00% 11,000 13.00% 11,000 13.00% 11,000
tablet/kapsul/kaplet 5 mg
Miconazole nitrate/ Miconazole/ Mikonazol krim 2
34 11000296 Dus, 24 tube @ 10 gr 13.00% 3,259 13.00% 3,259 13.00% 3,259 13.00% 3,259 13.00% 3,259
%
Salbutamol sulfate/ Salbutamol
45 11000262 Dus, 10 strip @10 tablet
tablet/kapsul/kaplet 4 mg
49 11000487 Vitamin B Kompleks tablet Dus, 10 strip @ 10 tablet 10.00% 11,182 10.00% 11,182 10.00%
Zinc sulfate/ Zinc sulfate monohydrate/Zinc/ Zinc Dus, 10 strip @10 tablet
50 11000144 50,091 13.00% 50,091 13.00%
tablet dispersible 20 mg dispersibel
I. KATEGORI OBAT LELANG PELAYANAN BPJS -REGULER (Non ID PAKET)
KEPULAUAN BANGKA
SUMATERA SELATAN BENGKULU NUSA TENGGARA BARAT KEPULAUAN RIAU ACEH
NO KODE NAMA OBAT KEMASAN BELITUNG
FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA
Dus, 10 strip @10 tablet
1 11000145 Albendazol tablet/kapsul/kaplet 400 mg 38,364 10.00%
kunyah
Amlodipin/Amlodipine/Amlodipine
2 11000151 Besylate/Amlodipine Besilate tablet/kapsul/kaplet Dus, 5 strip @10 tablet
10 mg
Amlodipin/Amlodipine/Amlodipine
3 11000150 Besylate/Amlodipine Besilate tablet/kapsul/kaplet 5 Dus, 5 strip @10 tablet
mg
Azitromisin/Azithromycin dihydrate Dus, 2 strip @10 kaptab
5 11000016 4.00% 32,327 4.00% 32,327 4.50% 32,327 4.50% 32,327 4.50% 32,327
tablet/kapsul/kaplet salut selaput 500 mg salut selaput
Clonidinehydrochloride/ Clonidine/ Klonidin
8 11000170 Dus, 10 strip @10 tablet 10.00% 16,636 10.00% 16,636 11.00% 18,273 11.00%
tablet/kapsul/kaplet 0,15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
9 11000033 Dus, 10 strip @ 10 tablet 13.00% 54,545 13.00% 54,545 13.50% 54,545 13.50% 59,727 13.50% 59,727
Kodein tablet/kapsul/kaplet 10 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
10 11000035 Dus, 10 strip @ 10 tablet 13.00% 94,182 13.00% 94,182 13.50% 94,182 13.50% 103,182 13.50% 103,182
Kodein tablet/kapsul/kaplet 15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
11 11000037 Dus, 10 strip @ 10 tablet 13.00% 124,000 13.00% 124,000 13.50% 124,000 13.50% 135,818 13.50% 135,818
Kodein tablet/kapsul/kaplet 20 mg
Dietilkarbamazin/ Diethylcarbamazine tablet 100
13 11000185 Dus, 10 strip @10 tablet 13.00% 14,909 13.50% 16,364 13.50% 16,364
mg
Fenobarbital/ Phenobarbital tablet/kapsul/kaplet
18 11000233 Dus, 10 strip @ 10 tablet 10.00% 16,364 10.00% 16,364 11.00% 16,364 11.00% 17,909 11.00% 17,909
30 mg
25 11000394 Hidrokortison/ Hydrocortisone krim 2,5 % Dus, 24 tube @ 5 gram 4.00% 2,250 4.00% 2,303 4.50% 2,303 4.50% 2,303 4.50% 2,303
27 11000395 Ketokonazol/ Ketoconazole krim 2% Dus,tube 10 gr 5.00% 2,289 5.00% 2,343 6.00% 2,343 6.00% 2,343 6.00% 2,343
kombinasi: ferro fumarat 60 mg + as. Folat 0,4 mg Dus, 10 strip @ 10 tablet
29 11000793 33,818 13.00% 33,818 13.50%
tablet salut gula (tablet tambah darah) salut gula
Metoclopramide hydrochloride (HCl)/
33 11000221 Metoclopramide/ Metoklopramid Dus, 10 strip @10 tablet 13.00% 11,000 13.00% 11,273 13.50% 11,273 13.50% 11,273 13.50% 11,273
tablet/kapsul/kaplet 5 mg
Miconazole nitrate/ Miconazole/ Mikonazol krim 2
34 11000296 Dus, 24 tube @ 10 gr 13.00% 3,259 13.00% 3,259 13.50% 3,259 13.50% 3,569 13.50% 3,569
%
Salbutamol sulfate/ Salbutamol
45 11000262 Dus, 10 strip @10 tablet
tablet/kapsul/kaplet 4 mg
49 11000487 Vitamin B Kompleks tablet Dus, 10 strip @ 10 tablet 11,182 10.00% 11,182 11.00%
Zinc sulfate/ Zinc sulfate monohydrate/Zinc/ Zinc Dus, 10 strip @10 tablet
50 11000144 50,091 13.50%
tablet dispersible 20 mg dispersibel
I. KATEGORI OBAT LELANG PELAYANAN BPJS -REGULER (Non ID PAKET)
KAL- TIMUR & KAL-
ACEH KALIMANTAN BARAT KALIMANTAN SELATAN KALIMANTAN TENGAH SULAWESI UTARA
NO KODE NAMA OBAT KEMASAN BARAT
FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA
Dus, 10 strip @10 tablet
1 11000145 Albendazol tablet/kapsul/kaplet 400 mg 42,091 11.00% 42,091 11.00% 42,091 11.00%
kunyah
Amlodipin/Amlodipine/Amlodipine
2 11000151 Besylate/Amlodipine Besilate tablet/kapsul/kaplet Dus, 5 strip @10 tablet 4,500 8.00%
10 mg
Amlodipin/Amlodipine/Amlodipine
3 11000150 Besylate/Amlodipine Besilate tablet/kapsul/kaplet 5 Dus, 5 strip @10 tablet
mg
Azitromisin/Azithromycin dihydrate Dus, 2 strip @10 kaptab
5 11000016 4.50% 32,327 4.50% 32,327 4.50% 32,327 5.00% 32,327 4.50% 32,327
tablet/kapsul/kaplet salut selaput 500 mg salut selaput
Clonidinehydrochloride/ Clonidine/ Klonidin
8 11000170 Dus, 10 strip @10 tablet 18,273 11.00% 19,000 12.00% 18,273 11.00% 18,273
tablet/kapsul/kaplet 0,15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
9 11000033 Dus, 10 strip @ 10 tablet 13.50% 59,727 13.50% 59,727 13.50% 62,273 15.50% 59,727 13.50% 59,727
Kodein tablet/kapsul/kaplet 10 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
10 11000035 Dus, 10 strip @ 10 tablet 13.50% 103,182 13.50% 103,182 13.50% 107,636 15.50% 103,182 13.50% 103,182
Kodein tablet/kapsul/kaplet 15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
11 11000037 Dus, 10 strip @ 10 tablet 13.50% 135,818 13.50% 135,818 13.50% 141,727 15.50% 135,818 13.50% 135,818
Kodein tablet/kapsul/kaplet 20 mg
Dietilkarbamazin/ Diethylcarbamazine tablet 100
13 11000185 Dus, 10 strip @10 tablet 13.50% 16,364 13.50%
mg
Fenobarbital/ Phenobarbital tablet/kapsul/kaplet
18 11000233 Dus, 10 strip @ 10 tablet 11.00% 17,909 11.00% 17,909 11.00% 18,636 12.00% 17,909 11.00% 17,909
30 mg
25 11000394 Hidrokortison/ Hydrocortisone krim 2,5 % Dus, 24 tube @ 5 gram 4.50% 2,303 4.50% 2,303 4.50% 2,303 5.00% 2,303 4.50% 2,407
27 11000395 Ketokonazol/ Ketoconazole krim 2% Dus,tube 10 gr 6.00% 2,343 6.00% 2,343 6.00% 2,343 8.00% 2,343 6.00% 2,449
kombinasi: ferro fumarat 60 mg + as. Folat 0,4 mg Dus, 10 strip @ 10 tablet
29 11000793 37,182 13.50%
tablet salut gula (tablet tambah darah) salut gula
Metoclopramide hydrochloride (HCl)/
33 11000221 Metoclopramide/ Metoklopramid Dus, 10 strip @10 tablet 13.50% 11,273 13.50% 11,273 13.50% 11,273 15.50% 11,273 13.50% 11,727
tablet/kapsul/kaplet 5 mg
Miconazole nitrate/ Miconazole/ Mikonazol krim 2
34 11000296 Dus, 24 tube @ 10 gr 13.50% 3,569 13.50% 3,569 13.50% 3,725 15.50% 3,569 13.50% 3,569
%
Salbutamol sulfate/ Salbutamol
45 11000262 Dus, 10 strip @10 tablet 7,182 5.00%
tablet/kapsul/kaplet 4 mg
49 11000487 Vitamin B Kompleks tablet Dus, 10 strip @ 10 tablet 12,273 11.00% 12,273 11.00% 12,273 11.00%
Zinc sulfate/ Zinc sulfate monohydrate/Zinc/ Zinc Dus, 10 strip @10 tablet
50 11000144 57,364 15.50% 54,909 13.50% 54,909
tablet dispersible 20 mg dispersibel
I. KATEGORI OBAT LELANG PELAYANAN BPJS -REGULER (Non ID PAKET)
SULAWESI SELATAN &
SULAWESI UTARA SULAWESI TENGAH SULAWESI TENGGARA GORONTALO NUSA TENGGARA TIMUR
NO KODE NAMA OBAT KEMASAN BARAT
FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA
Dus, 10 strip @10 tablet
1 11000145 Albendazol tablet/kapsul/kaplet 400 mg 44,000 12.00%
kunyah
Amlodipin/Amlodipine/Amlodipine
2 11000151 Besylate/Amlodipine Besilate tablet/kapsul/kaplet Dus, 5 strip @10 tablet 4,500 8.00% 4,500
10 mg
Amlodipin/Amlodipine/Amlodipine
3 11000150 Besylate/Amlodipine Besilate tablet/kapsul/kaplet 5 Dus, 5 strip @10 tablet 3,773
mg
Azitromisin/Azithromycin dihydrate Dus, 2 strip @10 kaptab
5 11000016 5.00% 32,327 5.00% 32,327 5.00% 32,327 5.00% 32,327 5.00% 32,327
tablet/kapsul/kaplet salut selaput 500 mg salut selaput
Clonidinehydrochloride/ Clonidine/ Klonidin
8 11000170 Dus, 10 strip @10 tablet 12.00% 19,000 12.00% 19,818
tablet/kapsul/kaplet 0,15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
9 11000033 Dus, 10 strip @ 10 tablet 15.50% 59,727 15.50% 59,727 15.50% 62,273 15.50% 62,273 15.50% 62,273
Kodein tablet/kapsul/kaplet 10 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
10 11000035 Dus, 10 strip @ 10 tablet 15.50% 103,182 15.50% 103,182 15.50% 107,636 15.50% 107,636 15.50% 112,182
Kodein tablet/kapsul/kaplet 15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
11 11000037 Dus, 10 strip @ 10 tablet 15.50% 135,818 15.50% 135,818 15.50% 141,727 15.50% 141,727 15.50% 147,636
Kodein tablet/kapsul/kaplet 20 mg
Dietilkarbamazin/ Diethylcarbamazine tablet 100
13 11000185 Dus, 10 strip @10 tablet
mg
Fenobarbital/ Phenobarbital tablet/kapsul/kaplet
18 11000233 Dus, 10 strip @ 10 tablet 12.00% 17,909 12.00% 17,909 12.00% 18,636 12.00% 18,636 12.00% 19,455
30 mg
25 11000394 Hidrokortison/ Hydrocortisone krim 2,5 % Dus, 24 tube @ 5 gram 5.00% 2,407 5.00% 2,407 5.00% 2,407 5.00% 2,407 5.00% 2,587
27 11000395 Ketokonazol/ Ketoconazole krim 2% Dus,tube 10 gr 8.00% 2,449 8.00% 2,449 8.00% 2,449 8.00% 2,449 8.00% 2,630
kombinasi: ferro fumarat 60 mg + as. Folat 0,4 mg Dus, 10 strip @ 10 tablet
29 11000793 38,818 15.50% 38,818 15.50%
tablet salut gula (tablet tambah darah) salut gula
Metoclopramide hydrochloride (HCl)/
33 11000221 Metoclopramide/ Metoklopramid Dus, 10 strip @10 tablet 15.50% 11,727 15.50% 11,727 15.50% 11,727 15.50% 11,727 15.50% 12,636
tablet/kapsul/kaplet 5 mg
Miconazole nitrate/ Miconazole/ Mikonazol krim 2
34 11000296 Dus, 24 tube @ 10 gr 15.50% 3,569 15.50% 3,569 15.50% 3,725 15.50% 3,725 15.50% 3,880
%
Salbutamol sulfate/ Salbutamol
45 11000262 Dus, 10 strip @10 tablet
tablet/kapsul/kaplet 4 mg
49 11000487 Vitamin B Kompleks tablet Dus, 10 strip @ 10 tablet 12,818 12.00% 13,364
Zinc sulfate/ Zinc sulfate monohydrate/Zinc/ Zinc Dus, 10 strip @10 tablet
50 11000144 15.50% 54,909 15.50%
tablet dispersible 20 mg dispersibel
I. KATEGORI OBAT LELANG PELAYANAN BPJS -REGULER (Non ID PAKET)
NUSA TENGGARA TIMUR MALUKU MALUKU UTARA PAPUA BARAT PAPUA
NO KODE NAMA OBAT KEMASAN
FEE
FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA HARGA FEE DIST
DIST
Dus, 10 strip @10 tablet
1 11000145 Albendazol tablet/kapsul/kaplet 400 mg 45,818 13.00%
kunyah
Amlodipin/Amlodipine/Amlodipine
2 11000151 Besylate/Amlodipine Besilate tablet/kapsul/kaplet Dus, 5 strip @10 tablet 10.00% 4,500 10.00% 4,500 10.00% 4,500 10.00% 4,500 10.00%
10 mg
Amlodipin/Amlodipine/Amlodipine
3 11000150 Besylate/Amlodipine Besilate tablet/kapsul/kaplet 5 Dus, 5 strip @10 tablet 7.00% 3,773 7.00% 3,773 7.00% 3,773 7.00% 3,773 7.00%
mg
Azitromisin/Azithromycin dihydrate Dus, 2 strip @10 kaptab
5 11000016 7.00% 32,327 7.00% 32,327 7.00% 32,327 7.00% 32,327 7.00%
tablet/kapsul/kaplet salut selaput 500 mg salut selaput
Clonidinehydrochloride/ Clonidine/ Klonidin
8 11000170 Dus, 10 strip @10 tablet 13.00% 19,818 13.00% 19,818 13.00%
tablet/kapsul/kaplet 0,15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
9 11000033 Dus, 10 strip @ 10 tablet 16.50% 62,273 16.50% 62,273 16.50% 62,273 16.50% 62,273 16.50%
Kodein tablet/kapsul/kaplet 10 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
10 11000035 Dus, 10 strip @ 10 tablet 16.50% 112,182 16.50% 112,182 16.50% 112,182 16.50% 112,182 16.50%
Kodein tablet/kapsul/kaplet 15 mg
CODEINE PHOSPHATE HEMIHYDRATE/ Codeine/
11 11000037 Dus, 10 strip @ 10 tablet 16.50% 147,636 16.50% 147,636 16.50% 147,636 16.50% 147,636 16.50%
Kodein tablet/kapsul/kaplet 20 mg
Dietilkarbamazin/ Diethylcarbamazine tablet 100
13 11000185 Dus, 10 strip @10 tablet 18,000 16.50%
mg
Fenobarbital/ Phenobarbital tablet/kapsul/kaplet
18 11000233 Dus, 10 strip @ 10 tablet 13.00% 19,455 13.00% 19,455 13.00% 19,455 13.00% 19,455 13.00%
30 mg
25 11000394 Hidrokortison/ Hydrocortisone krim 2,5 % Dus, 24 tube @ 5 gram 7.00% 2,587 7.00% 2,587 7.00% 2,587 7.00% 2,587 7.00%
27 11000395 Ketokonazol/ Ketoconazole krim 2% Dus,tube 10 gr 10.00% 2,630 10.00% 2,630 10.00% 2,630 10.00% 2,630 10.00%
kombinasi: ferro fumarat 60 mg + as. Folat 0,4 mg Dus, 10 strip @ 10 tablet
29 11000793 40,455 16.50% 40,455 16.50%
tablet salut gula (tablet tambah darah) salut gula
Metoclopramide hydrochloride (HCl)/
33 11000221 Metoclopramide/ Metoklopramid Dus, 10 strip @10 tablet 16.50% 12,636 16.50% 12,636 16.50% 12,636 16.50% 12,636 16.50%
tablet/kapsul/kaplet 5 mg
Miconazole nitrate/ Miconazole/ Mikonazol krim 2
34 11000296 Dus, 24 tube @ 10 gr 16.50% 3,880 16.50% 3,880 16.50% 3,880 16.50% 3,880 16.50%
%
Salbutamol sulfate/ Salbutamol
45 11000262 Dus, 10 strip @10 tablet
tablet/kapsul/kaplet 4 mg
49 11000487 Vitamin B Kompleks tablet Dus, 10 strip @ 10 tablet 13.00% 13,364 13.00%
Zinc sulfate/ Zinc sulfate monohydrate/Zinc/ Zinc Dus, 10 strip @10 tablet
50 11000144 59,818 16.50%
tablet dispersible 20 mg dispersibel
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)

KODE
HARGA TERENDAH LAMPUNG DKI & BANTEN BANTEN
NO KODE 1 NAMA GENERIK KEMASAN UOM HARGA BARU
TAMBAHAN
HNA FEE DIST HJP HARGA FEE DIST HARGA FEE DIST HARGA

35 11000310 Eugenol cairan Botol 10 ml Botol Eugenol cairan 17,113 13.00% 14,888 17,113 13.00% 17,113 13.00% 17,113
Pyridoxine/ Piridoksin (Vitamin B6) tab/kap/kapl
45 11000486 11000281 Dus, 10 strip @ 10 tablet
Pyridoxine/ Piridoksin
Dus (Vitamin B6) tab/kap/kapl
11,182
10 mg10.00%
(HCl) 10,064 11,182 10.00% 11,182 10.00% 11,182
10 mg (HCl)
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)

KODE
BANTEN DKI JAKARTA JAWA BARAT JAWA TENGAH & DIY JAWA TENGAH DI YOGYAKARTA
NO KODE 1 NAMA GENERIK KEMASAN
TAMBAHAN FEE FEE FEE FEE
HARGA FEE DIST HARGA HARGA FEE DIST HARGA HARGA
DIST DIST DIST DIST
35 11000310 Eugenol cairan Botol 10 ml 13.00% 17,113 13.00% 17,113 13.00% 17,113 13.00% 17,113 13.00% 17,113 13.00%
Pyridoxine/ Piridoksin (Vitamin B6) tab/kap/kapl
45 11000486 11000281 Dus, 10 strip @ 10 tablet 10.00% 11,182 10.00% 11,182 10.00% 11,182 10.00% 11,182 10.00% 11,182 10.00%
10 mg (HCl)
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)

KODE
JAWA TIMUR BALI SUMATERA UTARA SUMATERA BARAT RIAU JAMBI
NO KODE 1 NAMA GENERIK KEMASAN
TAMBAHAN FEE FEE FEE
HARGA FEE DIST HARGA FEE DIST HARGA HARGA HARGA HARGA
DIST DIST DIST
35 11000310 Eugenol cairan Botol 10 ml 17,113 13.00% 17,113 13.00% 17,968 13.00% 17,968 13.00% 17,968 13.00% 17,968
Pyridoxine/ Piridoksin (Vitamin B6) tab/kap/kapl
45 11000486 11000281 Dus, 10 strip @ 10 tablet 11,182 10.00% 11,182 10.00% 11,727 10.00% 11,727 10.00% 11,727 10.00% 11,727
10 mg (HCl)
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)
SUMATERA KEPULAUAN NUSA TENGGARA
JAMBI BENGKULU KEPULAUAN RIAU
NO KODE 1
KODE
NAMA GENERIK KEMASAN SELATAN BANGKA BELITUNG BARAT
TAMBAHAN FEE FEE
FEE DIST HARGA HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA
DIST DIST
35 11000310 Eugenol cairan Botol 10 ml 13.00% 17,968 13.00% 17,968 13.00% 17,968 13.50% 17,968 13.50% 19,680 13.50%
Pyridoxine/ Piridoksin (Vitamin B6) tab/kap/kapl
45 11000486 11000281 Dus, 10 strip @ 10 tablet 10.00% 11,727 10.00% 11,727 10.00% 11,727 11.00% 11,727 11.00% 12,818 11.00%
10 mg (HCl)
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)
KALIMANTAN KALIMANTAN KALIMANTAN KALIMANTAN
ACEH SULAWESI UTARA
NO KODE 1
KODE
NAMA GENERIK KEMASAN BARAT SELATAN TENGAH TIMUR & UTARA
TAMBAHAN FEE FEE FEE
HARGA HARGA HARGA FEE DIST HARGA FEE DIST HARGA HARGA
DIST DIST DIST
35 11000310 Eugenol cairan Botol 10 ml 19,680 13.50% 19,680 13.50% 19,680 13.50% 20,535 15.50% 19,680 13.50% 19,680
Pyridoxine/ Piridoksin (Vitamin B6) tab/kap/kapl
45 11000486 11000281 Dus, 10 strip @ 10 tablet 12,818 11.00% 12,818 11.00% 12,818 11.00% 13,455 12.00% 12,818 11.00% 12,818
10 mg (HCl)
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)
SULAWESI SULAWESI SELATAN SULAWESI NUSA TENGGARA
SULAWESI UTARA GORONTALO
NO KODE 1
KODE
NAMA GENERIK KEMASAN TENGAH & BARAT TENGGARA TIMUR
TAMBAHAN FEE FEE
HARGA HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST
DIST DIST
35 11000310 Eugenol cairan Botol 10 ml 15.50% 19,680 15.50% 19,680 15.50% 20,535 15.50% 20,535 15.50% 21,391 16.50%
Pyridoxine/ Piridoksin (Vitamin B6) tab/kap/kapl
45 11000486 11000281 Dus, 10 strip @ 10 tablet 12.00% 12,818 12.00% 12,818 12.00% 13,455 12.00% 13,455 12.00% 14,000 13.00%
10 mg (HCl)
II. KATEGORI OBAT NEGO PELAYANAN BPJS- REGULER (Non ID PAKET)

KODE
MALUKU MALUKU UTARA PAPUA BARAT PAPUA
NO KODE 1 NAMA GENERIK KEMASAN
TAMBAHAN
HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST HARGA FEE DIST

35 11000310 Eugenol cairan Botol 10 ml 21,391 16.50% 21,391 16.50% 21,391 16.50% 21,391 16.50%
Pyridoxine/ Piridoksin (Vitamin B6) tab/kap/kapl
45 11000486 11000281 Dus, 10 strip @ 10 tablet 14,000 13.00% 14,000 13.00% 14,000 13.00% 14,000 13.00%
10 mg (HCl)
 Lampiran : /UM 000/9230/IV/2019
DAFTAR PRODUK PENYETARAAN BPJS
PERIODE APRIL SD DESEMBER 2019

PERIODE APRIL SD
NO NAMA ZAT AKTIF (GENERIK)
DESEMBER 2019

1 11000145 Albendazol tablet/kapsul/kaplet 400 mg

2 11000008 Alprazolam tablet/kapsul/kaplet 0,5 mg

3 11000009 Alprazolam tablet/kapsul/kaplet 1 mg

Amlodipin/Amlodipine/Amlodipine
4 11000151 Besylate/Amlodipine Besilate
tablet/kapsul/kaplet 10 mg

5 11000150
6 11000170
7 11000171
Amlodipin/Amlodipine/Amlodipine
Besylate/Amlodipine Besilate
tablet/kapsul/kaplet 5 mg
Clonidinehydrochloride/ Clonidine/ Klonidin
tablet/kapsul/kaplet 0,15 mg
Clopidogrel bisulfate/ Clopidogrel/ Clopidogrel
hydrogen sulfate/ Klopidogrel
tablet/kapsul/kaplet salut selaput 75 mg

8 11000485
9 11000185
Cyanocobalamin/ Cyanocobalamine/
Sianokobalamin (vitamin B12)
tablet/kapsul/kaplet 50 mcg
Dietilkarbamazin/ Diethylcarbamazine tablet 100
mg

10 11000188 Dimenhidrinat tablet/kapsul/kaplet 50 mg

Eritromisin/ Erythromycin/ Erythromycin

11 11000065
stearate tablet/kapsul/kaplet 250 mg
Glibenklamid/ Glibenclamide
12 11000072 tablet/kapsul/kaplet 5 mg
Griseofulvin (micronized) tablet/kapsul/kaplet
13 11000202
125 mg

kombinasi: ferro fumarat 60 mg + as. Folat 0,4

14 11000793
mg tablet salut gula (tablet tambah darah)

Levofloxacin hemihydrate/
15 11000217 Levofloxacin/Levofloksasin tablet/kapsul/kaplet
salut selaput 500 mg

Methylergometrine Maleate/
16 11000104 Methylergometrine/ Metilergometrin
tablet/kaplet salut selaput 0,125 mg
 Pirantel pamoat/ Pyrantel Pamoate
17 11000248
tablet/kapsul/kaplet 125 mg

18 11000251 Pyrazinamide/ Pirazinamid tablet/kapsul/kaplet

500 mg

19 11000264 Simvastatin tablet/kaplet/salut selaput 10 mg

20 11000266 Simvastatin tablet/kaplet/salut selaput 20 mg

21 11000488 Tiamin (Vitamin B1) tablet/kapsul/kaplet 50 mg

22 11000487 Vitamin B Kompleks tablet

Zinc sulfate/ Zinc sulfate monohydrate/Zinc/ Zinc

23 11000144
tablet dispersible 20 mg
 KEMASAN ISI PAPUA

Dus, 10 strip @10

100 KF PEMENANG
tablet kunyah
Dus, 10 strip @10 100 11,818
tablet
Dus, 10 strip @10
100 14,909
tablet

Dus, 5 strip @10 tablet 50 KF PEMENANG

Dus, 5 strip @10 tablet 50 KF PEMENANG

Dus, 10 strip @10

100 19,909
tablet

Dus, 3 strip @10 tablet

30 48,273
salut selaput

Dus, 10 strip @10 100 5,182

tablet

Dus, 10 strip @10

100 19,091
tablet
botol plastik @ 100
100 KF PEMENANG
tablet
Dus, 10 strip @ 10
100 67,273
kapsul
Dus, 10 strip @10
tablet 100 13,545

Dus, 10 strip @10

100 23,091
tablet

Dus, 10 strip @ 10
100 40,455
tablet salut gula

Dus, 5 strip @10 tablet

50 25,227
salut selaput

Dus, 10 strip @10

100 KF PEMENANG
tablet
Dus, 25 catchcover @ 1
100 35,000
strip @ 4 tablet
Dus, 10 strip @10 100 24,000
tablet

Dus, 5 strip @10 tablet 50 5,318

Dus, 5 strip @10 tablet 50 11,227

Dus, 10 strip @10 100 9,273

tablet
Dus, 10 strip @ 10
100 9,273
tablet

Dus, 10 strip @10

100 59,818
tablet dispersibel
 NO.
KODE MATERIAL PROVINSI/NAMA OBAT
11000145 Albendazol tablet/kapsul/kaplet 400 mg
11000146 Alopurinol tablet/kapsul/kaplet 100 mg
11000008 Alprazolam tablet/kapsul/kaplet 0,5 mg
11000151 Amlodipine Besilate tablet/kapsul/kaplet 10 mg
11000150 Amlodipine Besilate tablet/kapsul/kaplet 5 mg
11000170 Klonidin tablet/kapsul/kaplet 0,15 mg
11000485 11000279 Sianokobalamin (vitamin B12) tablet/kapsul/kaplet 50 mcg
11000049 Diazepam tablet/kapsul/kaplet 2 mg
11000107 Natrium diklofenak tablet/kaplet salut enterik 25 mg
11000185 Dietilkarbamazin/ Diethylcarbamazine tablet 100 mg
11000188 Dimenhidrinat tablet/kaplet 50 mg
11000194 Ethambutol tablet/kapsul/kaplet 500 mg
11000072 Glibenklamid tablet/kapsul/kaplet 5 mg
11000073 Glimepiride tablet/kapsul/kaplet 1 mg
11000074 Glimepiride tablet/kapsul/kaplet 2 mg
11000075 Glimepiride tablet/kapsul/kaplet 3 mg
11000076 Glimepiride tablet/kapsul/kaplet 4 mg
11000202 Griseofulvin tablet/kapsul/kaplet 125 mg
11000210 Isoniazid tablet/kapsul/kaplet 300 mg
11000424 Captopril tablet/kaplet 25 mg
11000793 kombinasi: ferro fumarat 60 mg + as. Folat 0,4 mg tablet salut gula
11000217 Levofloksasin tablet/kapsul/kaplet salut selaput 500 mg
11000104 Metilergometrin tablet/kaplet salut selaput 0,125 mg
11000222 Metoklopramid tablet/kapsul/ kaplet 10 mg
11000227 Nifedipin tablet/kapsul/kaplet 10 mg
11000248 Pyrantel Pamoate tablet/kaplet 125 mg
11000309 Retinol (vitamin A) kapsul lunak 100.000 IU
11000304 Retinol acetate (vitamin A) kaps lunak 200.000 IU
11000124 Rifampisin tablet/kapsul/kaplet 450 mg
11000259 Salbutamol sulfate tablet/kaplet 2 mg
11000262 Salbutamol sulfate tablet/kaplet 4 mg
11000264 Simvastatin tablet/kaplet/ 10 mg
11000266 Simvastatin tablet/kaplet/ 20 mg
11000277 11000488 Tiamin (Vitamin B1) tablet/kapsul/kaplet 50 mg
11000487 11000487 Vitamin B Kompleks tablet
11000144 Zinc sulfate monohydrate tablet dispersible 20 mg
 30
HARGA BARU 2019 UOM PAPUA
Albendazol tablet/kapsul/kaple Dus
MINUS MARGIN Dus 10,636
Alprazolam tablet/kapsul/kaplet Dus 11,091
Amlodipin/Amlodipine/AmlodipinDus
Amlodipin/Amlodipine/AmlodipinDus
Clonidinehydrochloride/ Clonidi Dus 19,909
Cyanocobalamin/ CyanocobalamiDus 4,818
MINUS MARGIN Botol 7,818
MINUS MARGIN Dus 7,409
Dietilkarbamazin/ Diethylcarba Dus 17,909
Dimenhidrinat tablet/kapsul/ka Botol
TIDAK ADA PEMENANG Dus 54,300
Glibenklamid/ Glibenclamide ta Dus 13,545
MINUS MARGIN Dus
MINUS MARGIN Dus
MINUS MARGIN Dus
MINUS MARGIN Dus
Griseofulvin (micronized) table Dus 21,636
TURUN TAYANG Dus 16,727
TURUN TAYANG Dus 7,818
kombinasi: ferro fumarat 60 mg +Dus 40,455
Levofloxacin hemihydrate/ LevofDus 23,636
Methylergometrine Maleate/ Met Dus
MINUS MARGIN Dus
TIDAK ADA PEMENANG Dus 10,182
Pirantel pamoat/ Pyrantel Pamo Dus 32,818
MINUS MARGIN Botol
MINUS MARGIN Botol 29,455
TURUN TAYANG Dus
TURUN TAYANG Dus 5,818
TURUN TAYANG Dus 7,364
Simvastatin tablet/kaplet/salut Dus 5,000
Simvastatin tablet/kaplet/salut Dus 10,909
MINUS MARGIN Dus 8,727
Vitamin B Kompleks tablet Dus 8,727
Zinc sulfate/ Zinc sulfate monoh Dus 59,818