10 Formularium Hermina 1 FEB 2017edit

DAFTAR OBAT FORMULARIUM RUMAH SAKIT HERMINA DAAN MOGOT BERDASARKAN KELAS TERAPI
NO. NO.
BENTUK KETE-
KELAS URUT NAMA GENERIK KEKUATAN NAMA DAGANG
SEDIAAN RANGAN
TERAPI OBAT
1 ANALGESIK, ATIPIRETIK,
ANTIREMATIK, DAN ANTIPIRAI
1.1 ANALGESIK NARKOTIK
1 Fentanil Injeksi, Patch Injeksi 50 Fentanyl Injeksi; Durogesic
mcg/ml, Patch Patch
25 MU, 50
MU
2 Kodein HCl/Fosfat Tablet 20 mg Codikaf; Kodein Kimia Farma
(generik)
1
3 Morfin HCl Injeksi 10 mg/mL Morphine HCl KF

4 Morfin sulfat Tablet 10 mg MST
5 Petidin HCl Injeksi 50 mg/mL Clopedin; Pethidine HCl KF
1.2 ANALGESIK NON NARKOTIK
1 Antalgin (Metampiron/Metamizol) Tablet, Syrup, Tablet 500 Novalgin Syrup, Injeksi 250
Injeksi mg, Syrup mg; Santagesik Injeksi 500 mg;
50mg/ml, Antalgin Tablet (generik)
Injeksi 250
mg/ml, 500
mg/ml
2 Antalgin + Vitamin B complex Tablet 500 mg + B1 Neuralgin RX
50 mg + B6
10 mg + B12
10 mg
3 Antalgin + Diazepam Tablet 500 mg + 2 Danalgin; Analsik
mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
4 Asam Mefenamat Tablet 250 mg, 500 Argesid 500 mg Tablet; Ponstan
mg 500 mg; Mefinal 250 mg,
Mefinal 500 mg; Asam
Mefenamat 500 mg (generik)
5 Asetosal Tablet 80 mg, 100 Aspilet Chewable Tablet 80
mg, 160 mg mg; Ascardia 80 mg, 160 mg;
CardioAspirin 100 mg;
ThromboAspilet 80 mg
6 Deksketoprofen trometamol Tablet, Injeksi Tablet 25 mg, Ketesse injeksi; Tofedex Tablet,
Injeksi 50 Injeksi
2
mg/2 ml
ampul
7 Diklofenak Kalium Tablet, Serbuk Tablet 25 mg, Cataflam Tablet; Kalium
50 mg, Diclofenac Tablet 50 mg
Serbuk 50 mg (generik)
per sachet
(900 mg)
8 Diklofenak Natrium Tablet, Tablet 25 mg, Voltaren Tablet, SR Retard,
Emulgel, Tetes 50 mg, SR 75 Gel; Noncort MD; Natrium
Mata mg, Retard Diclofenac Tablet 50 mg
100 mg, Tetes (generik)
Mata 1
mg/ml,
Emulgel 1 %
20 g
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
9 Etorikoksib Tablet 90 mg, 120 Arcoxia

mg
10 Ibuprofen Tablet, Syrup, Tablet 200mg, Proris Tablet 200 mg, Syrup ,
Suppositoria 400 mg, Forte, Suppositoria; Bufect
Syrup 100 Syrup, Forte; Iprox Syrup,
mg/5ml, Forte Brufen syrup; Ibuprofen
200mg/5ml, Tablet 400 mg (generik)
Suppositoria
125 mg
11 Ketoprofen Tablet, Tablet 50mg, Kaltrofen Tablet 50 mg, 100mg,
3
Suppositoria 100 mg, CR Suppositoria; Pronalges Tablet,

Tablet 200 CR Tablet Suppositoria;
mg, Profenid Suppositoria;
Suppositoria Ketoprofen Tablet 50 mg,
100 mg 100mg (generik)
12 Ketorolak Tablet, Injeksi Tablet 10 mg, Farpain Tablet, Injeksi;
Injeksi 30 Ketopain Injeksi; Remopain
mg/ml Injeksi; Rativol Injeksi;
Ketorolac Injeksi (generik)
13 Meloksikam Tablet, Injeksi, Tlblet 7,5 mg, Movi-Cox Tablet; Velcox
Suppostoria 15 mg, Injeksi Tablet 15 mg, Injeksi; Ostelox
10 mg/ml, Suppositoria; Meloxicam
Suppositoria Tablet (generik)
15 mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
14 Metil Salisilat Krim, Larutan Krim (30 Counterpain Krim; Gandapura

gram), Larutan
Larutan 60 ml
15 Parasetamol Tablet, Syrup, Tablet 500 Dumin Tablet 500 mg; Sanmol
Drop, Infus, mg, 600 mg, Tablet 500 mg, Syrup 120
Suppositoria Syrup 120 mg/5ml, Drop, Infus; Naprex
mg/5ml, Syrup 250 mg/5ml, Drop;
160mg/5ml Proxion Syrup 120 mg/5ml,
250 mg/5ml, 250mg/5ml; Ottopan Drop,
4
Drop Syrup 120 mg/5ml; Tempra

100mg/ml, Syrup 160mg/5ml, 250mg/5ml,
Infus 1 gram, Drop; Panadol Tablet 500 mg
Suppositoria 600 mg, Syrup 160 mg/5ml,
125 mg, 250 Drop; Sumagesic tablet 600 mg;
mg Farmadol Infus; Tamoliv Infus;
Pyrex Infus; Pamol Drop,
Suppositoria; Poro
Suppositoria; Parasetamol
Tablet 500 mg, Syrup 120
mg/5ml, Drop, Infus (generik)
16 Parasetamol + N-Asetilsistein Tablet 500 mg + 200 Sistenol
mg
17 Parasetamol + Tramadol Tablet 325 mg + 37,5 Analtram; Ultracet; Sincronik
mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
18 Parasetamol + Vit B Kompleks Tablet 500 mg + B1 Dolo-Neurobion

50 mg + B6
10 mg + B12
10 mg
19 Parekoksib Injeksi 40 mg per vial Dynastat
20 Piroksikam Tablet, gel Tab 10 mg, Feldene, Piroksikam 10 mg
gel 5 % 15 tablet (generik)
gram, 20
gram
21 Selekoksib Kapsul 100 mg, 200 Celebrex
5
mg
22 Tramadol HCl Kapsul, Tablet, Kapsul/Tablet Tramal Tablet, Injeksi,
Injeksi, 50 mg, Injeksi Suppositoria, Tramadol HCl
Suppositoria 100 mg/2 mL Tablet, Injeksi (generik)
ampul,
Suppositoria
100 mg
1.3 ANTIREMATIK, ANTIPIRAI
1 Allopurinol Tablet 100 mg, 300 Zyloric, Allopurinol (generik)
mg
2 Asam Hyaluronat Inj 10 mg/mL Osflex, Dualvis
Syringe 2,5
mL
3 Kolkisin Tablet 0,5 mg Recolfar
4 Sulfasalazin Kaplet 500 mg Sulcolon
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
2 ANESTETIK
2.1 ANESTETIK LOKAL
1 Bupivakain HCl Injeksi 0,5 % spinal Marcain; Regivell
heavy, 0,5 %
spinal, 0,5 %
heavy
2 Lidokain HCl + adrenalin Injeksi 20 mg + Pehacain
0,0125 mg
3 Lidokain HCl Injeksi, Gel 2% Xylocain Gel; Lidocaine
injeksi (generik)
6
4 Lidokain HCl + Prilokain Krim 25 mg + 25 Dolones

mg (50 mg)
5 Lidokain HCl + Flukortolon Krim 20 mg + 1 Ultraproct N
mg
2.2 ANESTETIK UMUM
1 Isofluran Inhalasi cair 250 ml Sevodex; Isofluran (generik)
2 Ketamin HCl Injeksi 10 mg/ml Ketalar
3 Midazolam Injeksi 5 mg/5mL Dormicum; Midazolam-Hameln
amp, 15
mg/3mL
4 Propofol Injeksi 1 % dalam 20 Recofol N; Fresofol
mL
5 Sevofluran Cairan 250 mL Sevoran; Sevoflurane Baxter
3 ANTIALERGI DAN OBAT UNTUK
ANAFILAKSIS
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
1 Brompheniramin maleat + Pseudoefedrin Sirup 2 mg + 30 mg Alco Plus DMP

+ Dextromethorpan + 10 mg
2 Desloratadin Tablet, Syrup Tablet 5 mg, Aerius
Syrup 2,5
mg/5ml
4 Difenhidramin HCl Injeksi 10 mg/mL Decadryl
5 Dimentinden Maleat Drop 0,1% (10 ml) Fenistil
5 Deksklorpeniramin Maleat + Tablet, Syrup Tablet 2 mg + Dextamine
Deksametason 0,5 mg, Syrup
2 mg + 0,5
7
mg per 5ml
6 Deksklorpeniramin Maleat + Tablet, Syrup Tablet 2 mg + Celestamin Tablet, Syrup;
Betametason 0,25 mg, Colergis Syrup; Ocuson Tablet
Syrup 2 mg +
0,25 mg per
5ml
7 Deksklorpeniramin Maleat + Sirup 0,5 mg + 3,5 Intunal sirup
Fenilpropanolamin + Parasetamol + mg + 125 mg
Guaifenesin + Dekstrometorfan + 50 mg + 3,5
mg per 5 ml
8 Feksofenadin HCl Tablet Tablet OD Telfast OD, HD
120 mg,
Tablet HD
180 mg
9 Feksofenadin HCl + Pseudoefedrin Tablet 60 mg + 120 Fexofed
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
mg
10 Feniramin Maleat Tablet 25 mg Avil
11 Hidroksizin Tablet 25 mg, Bestalin
12 Homoklorsiklizin Tablet 10 mg Homoclomin
13 Isotipendil + Fenilefrin + Paracetamol Drop, Sirup Drop 1 mg + Nipe
1 mg + 120
mg per ml,
Syrup 2mg +
5 mg + 120
mg per 5ml
8
14 Klorfeniramin Maleat Tablet 4 mg Pehaclor, Alleron,

Chorpheniramine HCl
(generik)
15 Klorfeniramin Maleat + Tablet 2 mg + 15 mg Nalgestan
Fenilpropanolamin HCl
16 Klorfeniramin Maleat + Tablet 2 mg + 12,5 Fludane
Fenilpropanolamin HCl + Parasetamol mg + 500 mg
17 Klorfeniramin Maleat + Tablet 2 mg + 15 mg Neozep Forte
Fenilpropanolamin HCl + Parasetamol + + 250 mg +
Salisilsamid + Vitamin C 150 mg + 25
mg
18 Klorfeniramin Maleat + Pseudoefedrin Tablet 1 mg + 30 mg Decolsin
HCl + Parasetamol + Dekstrometorfan + + 400 mg +
Guaifenesin 10 mg + 50
mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
19 Loratadin Tablet, Sirup Tablet 10 mg, Claritin Tablet, Syrup; Alloris

Sirup Tablet, Syrup; Loratadin
5mg/5mL Tablet (generik)
Botol 60 mL
20 Loratadin + Pseudoefedrin Tablet 5 mg + 120 Rhinos SR; Aldisa; Clarinase
mg
21 Terfenadin + Pseudoefedrin Tablet, Sirup Tablet 40 mg Rhinofed
+ 30 mg,
Sirup 20 mg +
15 mg per 5
9
ml
22 Triprolidin + Pseudoefedrin Tablet, Sirup Tablet 2,5 mg Tremenza Tablet, Syrup;
+ 60 mg, Actifed Sirup, Librofed Syrup
Sirup 1,25 mg
30 mg per 5
ml
23 Triprolidin + Pseudoefedrin + Sirup Sirup 1,25 mg Actifed Expectorant, Lapifed
Guaifenesin + 30 mg + Expectorant
100 mg per 5
ml
24 Triprolidin + Pseudoefedrin + Sirup Sirup 1,25 mg Actifed Cough
Dextrometorfan + 30 mg + 10
mg per 5 ml
25 Pseudoefedrin Drop 7,5 mg per 0,8 Alco, Rhinos Neo, Triaminic
ml
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
26 Setirizin Tablet, Sirup, Tablet 10 mg, Cerini Tablet, Sirup, Drop;

Drop Sirup Cetinal Tablet; Ryvel Sirup,
5mg/mL, Drop; Ozen Drop; Tiriz Drop;
Drop 10 Cetirizine Tablet, Drop,
mg/mL Syrup (generik).
27 Siproheptadin Tablet 4 mg Pronicy, Heptasan
28 Levosetirizin Tablet 5 mg Xyzal
4 ANTIDOT DAN OBAT LAIN
UNTUK KERACUNAN
10
4.1 KHUSUS
1 Atropin Sulfat Injeksi Inj 1 mg/mL Atropine Sulfate (generik)
2 Biru Metilen Larutan 100 mL Metilen Blue
3 Kalsium Glukonat Inj. 100mg/mL Calsium Gluconate 10%
4 Kalsium Polistiren Sulfonat Serbuk 5g Kalitake
5 N-Asetilsistein Serbuk, Serbuk 100 Fluimucyl Serbuk 100 mg, 200
Kapsul, Tablet mg, 200 mg mg, Kapsul, Syrup, Injeksi;
Effervescent, Kapsul 200 Hidonac Injeksi; Pectocil Kasul;
Sirup, Injeksi mg, Tablet N-Asetil sistein Kapsul (test)
Effervescent
600 mg, Sirup
150 mg/5 mL,
Injeksi 300
mg/3ml
6 Nalokson HCl Inj 0,4 mg/mL Nokoba
7 Natrium Bikarbonat Tablet, Injeksi Tab 500 mg; Meylon 8,4%; Natrium
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Inj 8,4% Bikarbonat Tablet (generik)

5 ANTIEPILEPSI
1 Diazepam Tablet, Syrup, Tablet 5 mg, Valisanbe Tablet, Injeksi;
Injeksi; Syrup 2 mg/5 Stesolid Syrup, Injeksi, Rectal
Larutan ml, Injeksi 10 tube 5 mg, 10 mg
Rektal, Sirup mg/2mL,
Larutan rektal
tube (2,5 mL)
5 mg, 10 mg
11
2 Fenitoin Natrium Kapsul, Injeksi Kapsul 100 Ikaphen Injeksi; Dilantin

mg, Injeksi Kapsul; Phenytoin Kapsul,
100 mg/2mL Injeksi (generik)
3 Fenobarbital Injeksi 50mg/mL Sibital
4 Gabapentin Capsul 100 mg, 300 Alpentin 100 mg; Neurontin
mg 300 mg; Gabapentin 300 mg
(generik)
5 Karbamazepin Tablet 200 mg Tegretol; Bamgetol;
Cabamazepin (generik)
6 Klonazepam Tablet 2 mg Riklona 2
7 Magnesium Sulfat Injeksi 20%, 40% Magnesium Sulphate
(generik)
8 Okskabazepin Kaplet 300 mg, 600 Prolepsi, Trileptal 600 mg
mg
9 Pregabalin Capsul 75 mg Provelyn
10 Topiramat Tablet 25 mg, 50 mg Topamax Tab, Topamax
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Sprinkle
11 Valproat (dalam bentuk asam/natrium) Tablet, Sirup Tablet 250 Depakene Syrup, Depakote
mg, 500 mg; Tablet, Tablet ER 250 mg, 500
Syrup 250 mg; Valeptik Syrup; Valepsi
mg/5mL Syrup; Lepsio Syrup; Valproat
Acid Syrup (generik)
6 ANTIMIKROBA
6.1 ANTELMINTIK INTESTINAL
1 Mebendazol Tablet 500 mg Vermox
12
2. Pirantel Pamoat Tablet, Tablet 250 Combantrin

Suspensi mg, Suspensi
10 mL (125
mg/5mL)
6.2 ANTIBAKTERI
6.2.1 Golongan Penisilin
1 Amoksisilin Kapsul, Kapsul 250 Amoxan Kapsul 250 mg, Kaplet
Kalpet, Syrup mg, Kaplet 500 mg, Drop, Syrup, Syrup
kering, Injeksi 500 mg, Forte, Inj; Amoxicillin Syrup
Syrup 125 kering 125 mg/5mL, Tablet
mg/5mL, 500 mg (generik)
Syrup Forte
250 mg/5mL,
Drop
100mg/mL
Injeksi 1 g/
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
vial
2 Amoksisilin + Klavulanat Tablet, Syrup Tablet 500 mg Clavamox Tablet, Syrup;
+ 125 mg; Amiclav Tablet; Daxet Tablet;
Syrup 125 Claneksi Tablet, Syrup, Syrup
mg/5mL, Forte, Injeksi; Clabat Syrup,
Syrup Forte Syrup Forte; Co-Amoxiclave
250 mg / 5 Tablet (generik)
mL, Injeksi 1
gram
13
3 Ampisilin Tablet 500 mg Ampisillin (generik)

4 Ampisilin + Sulbaktam Tablet, Injeksi Injeksi 750 Bactesyn Tablet, Injeksi 750
mg, 1,5 g/ mg, 1,5 g; Cinam Injeksi 1,5 g
vial; Tablet
375 mg
5 Benzatin Benzilpenisilin Injeksi 2,4 juta IU Benzatin Benzilpenisilin
(generik)
6 Piperasilin + Tazobaktam Injeksi 4,5 gram / vial Pybactam
6.2.2 Golongan Aminoglikosida
1 Amikasin Injeksi 250 mg, 500 Mikasin 250 mg; Amiosin
mg 500mg; Glybotic 250 mg;
Amikasin 500 mg (generik)
2 Gentamisin Injeksi, Krim, Injeksi 80 Garamycin Krim, Salep;
Tetes mg/2mL; Sagestam Krim, Injeksi; Cendo
Mata/Telinga, Krim 0,1%, Gentamisin ED, EO;
Salep Mata Tetes Gentamisin Krim, Salep, EO
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Mata/Telinga (generik)
3%, Salep
Mata 3%
3 Linkomisin Kapsul 250 mg, 500 Lincocin 250 mg, 500 mg;
mg Lincomycin 500 mg (generik).
6.2.3 Golongan Kloramfenikol
1 Kloramfenikol Kapsul, Syrup, Kapsul 250 Colsancetin Kapsul, Syrup,
Injeksi mg, Syrup Injeksi; Chloramfenicol
125 mg/5mL, Kapsul (generik)
14
Injeksi 1gram
2 Tiamfenikol Kapsul, Sirup Kapsul 250 Biothicol Kapsul, Sirup Kering
mg, 500 mg, 125mg/5mL, Sirup Kering
Sirup 125 Forte 250 mg/mL; Thiamycin
mg/5mL, Sirup Kering 125mg/5mL,
Sirup Forte Sirup Kering Forte 250 mg/mL
250 mg/5mL
6.2.4 Golongan Kuinolon
1 Levofloksasin Tablet, Infus Tablet 500 Levocin Tablet, Infus 500 mg;
mg, Infus 500 Cravit Infus 750 mg; Cravox
mg, Infus 750 Infus 750 mg; Prolecin Tablet,
mg Syrup; Volox Tablet;
Levofloxacin Tablet 500 mg,
Infus 500 mg, 750 mg
(generik)
2 Ofloksasin Tablet 400 mg Ofloxacin (generik)
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
3 Siprofloksasin Tablet, Infus Tablet 500 Baquinor Forte Tablet, Infus,;

mg, Infus 500 Tequinol Tablet; Ciproxin
mg Tablet; Interflox Infus;
Ciprofloxacin Tablet, Infus
(generik)
6.2.5 Golongan Makrolida
1 Azitromisin Tablet, Kapsul, Kapsul 250 Zithromax Tablet 500 mg,
Sirup Kering, mg, 500 mg, Injeksi; Zibramax Tablet 500
Injeksi Tablet 500 mg, Sirup Kering; Zistic Tablet
15
mg, Sirup 500 mg; Zithrax Tablet 500 mg;

Kering Zycin Tablet 500mg; Mezatrin
250/mL, 250 mg Kapsul; Maxmor Sirup
Injeksi 500 Kering, Azithromycin Tablet
mg 500 mg (generik)
2 Eritromisin Stearat Tablet Tablet Erysanbe Chewable 200 mg,
Kunyah, Kunyah 200 Tablet 500 mg, Sirup Kering,
Tablet, Sirup mg, Tablet Erythromycin Tablet 250 mg
Kering 250 mg, 500 (generik)
mg, Sirup 200
mg/mL.
3 Klaritromisin Tablet, Sirup Tablet 250 Abbotic Sirup Kering 125
mg, 500 mg, mg/mL (30 ml, 60 ml), 250
Sirup 125 mg/mL; Bicrolid Tablet 250
mg/mL, 250 mg, 500 mg; Comtro Syrup 125
mg/mL.
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
4 Roksitromisin Tablet 150 mg Uplores

5 Spiramisin Tablet, Sirup Tablet 500 Rovamycin Tablet 1,5 MIU,
mg, 1,5 MIU, Spirolin Tablet 500 mg,
Sirup 125 Osmycin Sirup; Spiramycin
mg/5 mL. Tablet 500 mg (generik)
6.2.6 Golongan Sefalosporin
1 Sefadroksil Kapsul, Sirup Kapsul 250 Cefat Kapsul 250 mg, 500 mg,
Kering, Drop mg, 500 mg, Sirup Kering 125 mg/mL, 250
Sirup 125 mg/mL; Renasistin Sirup 125
16
mg/mL, 250 mg/5 ml, Drop; Qidrox Kapsul

mg/mL, Drop 500 mg, Sirup 125 mg/mL;
150 mg/ml Valos Kapsul 500 mg; Vroxil
Kapsul 500 mg; Cefadroxil
500 mg Kapsul, Dry Sirup 250
mg/5mL (generik).
2 Sefaklor Tablet, Syrup Kaplet 500 Cloracef
mg, Syrup
125 mg/5mL.
3 Sefditoren Pivoksil Tablet 200 mg Meiact
4 Sefepim Injeksi 1 gram Vipime; Ceforim; Cefepime
(generik).
5 Sefeksim Kapsul, Sirup Kapsul 50 Cefspan kapsul 100 mg, 200
Kering mg, 100 mg, mg, sirup kering; Cefila kapsul
200 mg, Sirup 100 mg, 200 mg, sirup kering;
Kering 100 Sporetik kapsul 50 mg, 100 mg,
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
mg/5 mL sirup kering; Anfix Kapsul 100

mg; Simfix Kapsul 100 mg,
Sirup Kering; Ceptik Kapsul
200 mg; Sofix 100 mg; Cefixim
Kaspul 100 mg, 200 mg, Sirup
kering (generik).
6 Sefoperazon Inj 1 Gram Bifotik; Cefoperazone 1 gram
Injeksi (generik).
7 Sefoperazon + Sulbaktam Inj 500 mg + 500 Sefobactam 1 gram,
17
mg Sefoperazone-Sulbactam 1
gram Injeksi (generik)
8 Sefotaksim Inj 0,5 gram, 1 Clatax 1 gram, Ethiclaf 1 gram,
gram Simexim 1 gram; Goforan 1
gram, Kalfoxim 500 mg & 1
gram, Taxegram 0,5 gram & 1
gram, Cefotaxim 1 gram
(generik).
9 Sefprozil Syrup 125 mg/ 5 ml Lizor
10 Seftazidim Injeksi 1 gram Zidifec; Ceftazidime (generik)
11 Seftriakson Injeksi 1 gram Elpicef; Cefxon; Foricef;
Starxon; Terfacef; Tricefin;
Broadced; Betrix; Ceftriaxon
(generik)
12 Sefuroksim Kapsul, Injeksi 500 mg; Sharox Kapsul, Injeksi; Celocid
Injeksi 750 Injeksi.
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
mg
6.2.7 Golongan Tetrasiklin
1 Doksisiklin Kapsul 100 mg Siclidon; Doxycycline
(generik)
6.2.8 Golongan Lain-Lain
1 Doripenem Injeksi 1 gram Doripenem (generik)
Fradiomisin + Gramisidin Tablet Hisap 2,5 mg + 1 FG Troches
mg
2 Fosfomisin Injeksi; serbuk 1 gram, 2 Novellmycine injeksi 1 gram;
18
gram, 3 gram Monuril sachet 3 gram;

(sachet) Fosfomicin Injeksi 1 gram, 2
gram (generik)
3 Imipenem + Silastatin Injeksi 500 mg + 500 Pelastin; Timipen
mg per 120
ml vial
4 Klindamisin Kapsul 150 mg, 300 Dalacin C150 mg, 300 mg;
mg Clindaman 150 mg, 300 mg;
Prolic 150 mg, 300 mg;
Clindamycin 300 mg (generik)
5 Kolistin Tablet 1.500.000 IU Colistine
6 Kotrimoksazol (TMP + SMZ) Tablet; Tablet 80 mg Sanprima Tablet, Forte,
Suspensi + 400 mg, Suspensi; Cotrimoxazole
Tablet Forte Tablet (generik)
160 mg + 800
mg; suspensi
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
40 mg + 200
mg per 5 ml
7 Meropenem Injeksi 500 mg, 1 Meronem 500 mg; Merofen 500
gram mg, 1 gram; Merosan 500 mg, 1
gram; Merotik 500 mg;
Meropenem 500 mg (generik)
8 Metronidazol Tablet; Infus; Tablet Forte Flagyl Tablet Forte, Infus,
Syrup; Ovula 500 mg; Infus Syrup, Ovula 500 mg, 1 gram;
500 ml/kolf; Trichodazol Tablet, Infus;
19
Syrup 125 Metronidazole Tablet Forte,

ml/5 ml; Infus (generik)
Ovula 500mg,
1 gram
9 Nifuroksazid Syrup 250 mg/5ml Nifural; Sanfuro
10 Vankomisin Injeksi 500 mg Vancep
6.3 ANTITUBERKULOSIS
1 Etambutol Tablet 250 mg, 500 Etibi 500 mg; Ethambutol 500
mg mg (generik)
2 Etambutol + Isoniazid + Vit B6 Tablet Tablet 250 mg Bacbuthin
+ 100 mg + 5
mg, Tablet
Forte 500 mg
+ 200 mg +
10 mg
3 Isoniazid Tablet 300 mg Isoniazid 300 mg (generik)
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
4 Isoniazid + Vit B6 Tablet, Syrup 100 mg, 300 INH Ciba Tablet 300 mg;
mg, 400 mg; Pehadoxin, Syrup; TB Vit
100 mg + 10 Tablet 400 mg
mg /5 ml
5 Pirazinamid Tablet 500 mg Pezeta; Sanazet; Pyrazinamide
(generik)
6 Rifampisin Kaplet 300 mg, 450 Rifamtibi 450 mg; Rimactane
mg, 600 mg 450 mg; Rifampicin 300 mg,
450 mg, 600 mg (generik)
20
7 Rifampisin + INH Tablet Salut 450 mg + 300 Rimactazid Tablet, Tablet Pead
Selaput mg; Pead: 75
mg + 50 mg
8 Rifampisin + INH + Pirazinamid Tablet 150 mg + 75 Rimcure 3 FDC, Pead
mg + 400 mg;
Pead : 75 mg
+ 50 mg +
150 mg
9 Streptomisin Sulfat Injeksi 1 gram Steptomycin Sulphate
(generik)
6.4 ANTIFUNGI
1 Flukonazol Kapsul; Infus Kapsul 50 Diflucan Kapsul 50 mg, 150
mg, 150 mg; mg; Flucoral Kapsul 50 mg,
Injeksi 2 150 mg; Govazol Kapsul150
mg/ml vial mg; Zemyc Kapsul 50 mg, 150
100 ml mg, Flukonazol Kapsul 150
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
mg, Infus (generik)

2 Itrakonazol Capsul 100 mg Sporacid
3 Ketokonazol Tablet, Krim Tablet 200 Mycoral Tablet, Cream;
mg, Krim 20 Formyco Tablet, Cream;
mg Ketokonazol Tablet, Cream
(generik)
4 Metronidazol + Nystatin Ovula 500 mg + Flagystatin; Fladystin;
10.000 UI Neogynoxa
5 Nistatin Tablet; Drop Tablet Mycostatin drop; Candistatin
21
500.000 IU; Drop; Constantia Drop; Nymico

Drop 100.000 Drop; Nystatin Tablet
IU/ml (generik)
6.5 ANTIVIRUS
1 Asiklovir Tablet, Injeksi, Tablet 200 Zovirax Tablet 200 mg, cream,
Eye Oint, mg, 400 mg; Eye Oint, Injeksi; Acyclovir
Cream Injeksi 250 Tablet 200 mg, 400 mg, cream
mg, 500 mg; 5% (generik)
Eye Oint 3%,
Cream 5%
2 Gansiklovir Injeksi 500 mg Cymevene
3 Entekavir Tablet 0,5 mg Baraclude
4 Metisoprinol Tablet, Syrup Tablet 500 Isoprinosine Tablet, Syrup;
mg; Syrup Laporosin Tablet, Syrup;
250 mg/5ml Isprinol Tablet, Syrup
5 Telbivudin Tablet 600 mg Sebivo
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
6 Valasiklovir Tablet 500 mg Herclov

7 ANTIMIGRAIN / VERTIGO
7.1 ANTIMIGRAIN
1 Ergotamin Tablet 1 mg Ericaf
2 Ergotamin + Kafein Tablet 1 mg + 100 Cafergot
mg
3 Flunarizin Tablet 5 mg, 10 mg Sibelium 5 mg; Flunarizine 5
mg, 10 mg (generik)
4 Pizotifen Tablet 500 mcg Lysagor
22
5 Sinarin Tablet 25 mg Stugeron

6 Sumatriptan Tablet 100 mg Triptagic
7.2 ANTIVERTIGO
1 Betahistin diHCl Tablet 8 mg, 24 mg Betaserc 8 mg, 24 mg
2 Betahistin Mesilat Tablet 6 mg, 12 mg, Merislon 6 mg, 12 mg;
8 mg, 24 mg Vertigosan tablet; Betahistine 6
mg (generik)
8 ANTINEOPLASTIK DAN OBAT
UNTUK TERAPI PALIATIF
8.1 ANTIHORMON
1 Anastrozol Tablet 1 mg Arimidex
2 Letrozol Tablet 2,5 mg Femara
3 Leuprorelin Asetat Injeksi 3,75 mg Tapros, Endroline
4 Tamoksifen Sitrat Tablet 10 mg Tamofen
8.2 ANTINEOPLASTIK
1 5-Fluorourasil Injeksi 500 mg/10 ml Curacil
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
vial
2 Bleomisin Injeksi 15 mg/ampul Bleocin
3 Doxorubisin Injeksi 50 mg/25 ml Sindroksin
4 Dosetaksel Injeksi 20 mg/0,5 ml, Brexel
80 mg/ 2 ml
5 Epirubicin HCl Injeksi 50 mg/25ml Epirubicin
6 Kapesitabin Tablet Salut 500 mg Xeloda
Film
7 Metotreksat Tablet, Injeksi Tablet 2,5 Methotrexate
23
mg; Injeksi 50
mg/2 ml
8 Rituksimab Injeksi 500 mg/50 ml Mabthera
9 Sisplatin Injeksi 50 mg/50 ml Cisplatin
10 Vikristin Injeksi 2 mg/ 2 ml Vricristine
9 ANTIPARKINSON/DEMENTIA
9.1 ANTIPARKINSON
1 Bromokriptin Tablet 2,5 mg Cripsa
2 Levodopa Tablet 100 mg Madopar
3 Triheksifenidil HCl Tablet 2 mg Heximer, Trihexyphenidyl
(generik)
4 Ropinirole Tablet 2 mg Requip
9.2 OBAT DEMETIA
1 Donepezil Tablet 5 mg Fordesia
10 OBAT YANG MEMPENGARUHI
DARAH
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
10.1 ANTIANEMIA
1 Asam Folat Tablet 400 mcg, Folavit 400 mcg, 1000 mcg;
1000 mcg, 5 Asam Folat 1 mg, 5 mg
mg (generik)
2 Besi Sukrosa Injeksi 100 mg/5 ml Venofer
3 Besi (II) dlm bentuk garam sulfat, Tablet, Sirup, Kombinasi Emineton Tablet; Hemobion
fumarat Drop Tablet; Ferofort Tablet;
Sangobion Tablet, Sirup, Drop;
Ferizz Sirup, Drop; Ferlin Drop
24
4 Kompleks Besi (III) Hidroksida Tablet, Sirup, Tablet 357 mg Maltofer Fol Chewable Tablet,
Polimaltose (IPC) + Asam Folat Drop + 350 mcg Sirup, Drop
5 Vitamin B12 (sianokobalamin) Tablet 50 mcg Vitamin B12 (generik)
10.2 OBAT YANG MEMPENGARUHI
DARAH
1 Asetosal Tablet 80 mg, 100 Aspilet Chewable Tablet 80
mg, 160 mg mg; Ascardia 80 mg, 160 mg;
CardioAspirin 100 mg;
ThromboAspilet 80 mg
2 Enoksaparin Natrium Injeksi 40 mg/0,4ml, Lovenox
60 mg/0,6 ml
3 Fondaparinux Natrium Injeksi 2,5mg/0,5 ml, Arixtra
7,5 mg/0,6 ml
4 Heparin dialisat Gel (20 gram) Thrombophob
5 Heparin Natrium Injeksi 25.000 Inviclot
IU/5ml
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
6 Klopidogrel Tablet 75 mg Plavix; CPG; Clopidogrel

(generik)
7 Lumbricus Kapsul 250 mg Disolf
8 Rivaroksaban Tablet 10 mg, 20 mg Xarelto
9 Silostazol Tablet 50 mg, 100 Pletaal
mg
10 Streptokinase Injeksi 1.500.000 IU Streptase
12 Tiklopidin Tablet 250 mg Agulan
13 Warfarin Tablet 2 mg Simarc
25
10.3 HEMOSTATIK
1 Asam Traneksamat Tablet, Injeksi Tablet 500 Kalnex Tablet 500 mg, Injeksi
mg, Injeksi 500 mg; Plasminex Injeksi 500
250mg/5ml mg; Tranec Injeksi 250 mg;
ampul, 500 Asam Traneksamat Tablet
mg/5ml 500 mg, Injeksi 250 mg, 500
ampul mg (generik)
2 Etamsilat Tablet, Injeksi Tablet 500 Dicynone
mg, 250 mg/2
ml
3 Karbazokrom Tablet, Injeksi Tablet 10 mg, Adona (AC17) Tablet, Forte,
Tablet Forte Injeksi 25 mg, 50 mg;
30 mg; Injeksi Karbazokrom Injeksi 50 mg
25 mg/5ml, (generik)
50 mg/10 ml
4 Vitamin K1 Injeksi 2 mg/ml Prohem; Neo-K; Vitadion;
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
(Phytomenadione/phytonadione) Phytomenadione (generik)

5 Vitamin K3 (Menadione) Injeksi Vitamin K3
10.4 HEMATOPOETIK
1 Eritropoietin Alfa Pre-filled Epotrex
syringe
2 Eritropoietin Beta Injeksi 2.000 IU Recormon
3 Rekombinan Human Eritropoetin Injeksi 3.000 IU Hemapo
4 Filgrastim (GCSF) Injeksi 300 mcg Leukokine
5 Lenograstim Injeksi 33,6 MIU Granocyte
26
atau 263
mcg/ml
11 PRODUK DARAH DAN
PENGGANTI PLASMA
11.1 FRAKSI PLASMA UNTUK
PEMAKAIAN KHUSUS
1 Albumin (Human Albumin) Injeksi 20% 50 ml, Octalbin 25% 5 ml, 100 ml;
20% 100 ml, Plasbumin 25% 20 ml50 ml,
25% 20 ml, 100 ml;100 ml; Albuminar 25%
25% 50 ml, 100 ml;
25% 100 ml
11.2 PENGGANTI PLASMA
1 Dextra 70 Infus 6% Otsutran 70
2 Hidroksietil Pati (HES) Infus 6% (500ml) Sanbe Hest 130; Voluven
3 Poligelin (gelatin polisusinat) Infus 4% (500 ml Gelofusal; Gelofusin
12 DIAGNOSTIK
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
12.1 OBAT KONTRAS

1 Barium Sulfat Serbuk Barium Sulfat E-Z-HD764
2 Iodine Larutan 320 mg/ml Omnipaque; Iopamiro
dalam vial
100 ml
13 ANTISEPTIK DAN DESINFEKTAN
13.1 ANTISEPTIK
1 Alkohol Larutan, Swab 70%; Alkohol 70% 100 ml; Wippy
Swab
27
2 Etakridin Lakta (Rivanol) Larutan 0,1% Rivanol

3 Hidrogen Peroksida Larutan 3% (30 ml, H2O2
60ml)
Ikhtamolum Salep 0,1gram (15 Ichtyol
gram)
4 Iodin Povidon Larutan 10%, 1% Betadine Solution (10%),
Vaginal Douche (10%),
Feminime Hygiene (10%)
Gargle (1%); Povidone Iodine
Solution (10%) (generik)
5 Kalium Permanganat Serbuk 5 gram PK Kristal
6 Klorheksidine Glukonat Larutan 0,2% Minosep Gargle
7 Polikresulen Larurat Larutan Albothyl
konsentrat, Konsentral
Ovula 36% (10 ml,
100 ml),
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Ovula 90 mg
13.2 DESINFEKTAN
1 Formalin Larutan 10% Formalin Nuetral Buffer
2 Klorheksidine Diglukonat Larutan 4% Microshield
3 Orto-ftalaldehid Larutan 5L Cidex 14
14 OBAT UNTUK GIGI DAN MULUT
14.1 OBAT TOPIKAL UNTUK GIGI DAN
MULUT
1 Benzidamin HCl Larutan 7,5 mg/5ml Tantum Verde Oral Rinse
28
2 Boraks Gliserin Larutan 10% GOM

3 Iodin Povidon Larutan 1% Betadine Gargle (1%)
4 Klorheksidine Glukonat Larutan 0,2% Minosep Gargle
5 Maltodektrin Aqua, Propilen Glikol Gargle, Gel Gargle 60 ml, Aloclair
Gel 8 ml
15 DIURETIK
1 Furosemid Tablet, Injeksi Tablet 40 mg, Lasix Tablet; Injeksi; Uresix
Injeksi 20 Injeksi; Roxemid Injeksi;
mg/2ml Furosemide Tablet, Injeksi
(generik)
2 Hidroklortiazid Tablet 25 mg HCT (generik)
3 Manitol Larutan 20% Manitol
4 Sprironolakton Tablet 25 mg, 100 Aldactone 25 mg; Letnotal 25
mg mg; Spironolactone 25mg, 100
mg (generik)
16 HORMON, ENDOKRIN LAIN, DAN
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
KONTRASEPSI
16.1 ANIDIABETIK
16.1.1 Antidiabetik Oral
1 Akarbose Tablet 50 mg, 100 Glucobay 50 mg, 100 mg;
mg Acarbose 100 mg (generik)
2 Dafaglifozin Tablet 10 mg Forxiga
3 Glibenklamid Tablet 5 mg Glibenklamid (generik)
4 Glikazid Tablet 30 mg Diamicron MR
5 Glikuidon Tablet 30 mg Glurenorm; Gliquidone
29
(generik)
6 Glimepiride Tablet 1 mg, 2 mg, 3 Amaryl 2mg, 4mg;
mg, 4 mg Glimepiride 1 mg, 2mg, 3 mg
(generik)
7 Glimepiride + Metformin Tablet 2 mg + 500 Amaryl M
mg
8 Metformin HCl Tablet, XR Tablet 500 Glugophage Tablet 500 mg, 850
Tablet mg, 850 mg; mg, Tablet XR 850 mg; Efomet
XR Tablet 500 mg; Metformin 500 mg
850 mg (generik)
9 Metformin HCl + Glibenklamid Tablet 500 mg + 5 Glucovance
mg; 500 mg +
5 mg; 250 mg
+ 1,25 mg
10 Sitagliptin Tablet 100 mg Januvia
11 Sitagliptin + Meformin HCl Tablet 50 mg + 500 Janumed
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
mg; 50 mg +
1000 mg
12 Vildagliptin Tablet 50 mg Galvus
16.1.2 Antidiabeik Parenteral
1 Insulin Analog Aspart Injeksi 100 IU/3 ml Novorapid Flexpen
2 Insulin Analog Campur (Aspart + NPH) Injeksi 100 IU/3 ml Novomix Flexpen
3 Insulin Analog Detemir Injeksi 100 IU/3 ml Levemir Flexpen
4 Insulin Analog Gargline Penfill 100 IU/3 ml Lantus Solostar
5 Insulin Reguler Injeksi 100 IU/ml Actrapid HM
30
16.2 HORMON KELAMIN OBAT YANG

MEMPENGARUHI FERTILITAS
16.2.1 GnRH Analog, FSH/LH
1 Mesterolone Tablet 25 mg Infelon
2 Ovidrel HCG Injeksi 250 mcg Ovidrel
3 Rekombinan FSH Injeksi Gonal F
4 Testosteron Injeksi 250 Sustanon 250; Nebido
mg/ampul`
16.2.2 Estrogen
1. Estrogen Tablet 0,625 mg Osthero
2 Estradiol Tablet salut Tab salut film Ovestin (krim), Progynova (salu
film, krim 1 mg, krim 15 film)
g
3 Estradiol Falerat Tablet 2 mg Cyclo-progynova
4. Etinilestradiol Tablet 50 mcg Lynoral
5. Siproteron Asetat + Etinilestradiol Tablet 2 mg + 0,035 Diane
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
m
16.2.3 Progesteron
1. Allylesrenol Tablet 5 mg Preabor; Pregnolin; Premaston
2. Didrogesteon Tablet 10 mg Duphaston
3 Noretisteron Tablet 5 mg Primolut-N
4 Nomegestrol Asetat Kaplet 5 mg Lutenyl
5 Progesteron Ovula, Tablet 400 mg Cygest (ovula); Utrogestan
(ovula), 100 (tablet/ovula)
mg
31
(tab/ovula)
6. Medroksi Progesteron asetat Tablet 5 mg, 10 mg Provera
7 Medroksiprogesteron Injeksi Depo-progestin
16.2.4 Kontraseptik
1. Kombinasi dropirenon + etinilestradiol Tablet 3 mg + 0,03 Yasmin, Yaz
mg, 3 mg
+0,02 mg
2. Levonorgestrel + Etinilestradiol Tablet 150 mcg + 30 Microgynon
mcg
3 Levonorgestrel Tablet 30 mcg Mirena
4 Medroksi Progesteron asetat + Eastradiol Injeksi Depo 0,5 ml Cyclofem
sipionat
16.2.5 Induktor Ovulasi
1 HCG Injeksi 1500 IU, 5000 Pregnyl
IU
2 Klomifen Sitrat Tablet 50 mg Profertil, Pinfetil, Blesifen
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
16.3 HORMON TIROID DAN

ANTITIROID
1 Thymazol Tablet 10 mg Thyrozol
2 Propiltiourasil Tablet 50 mg; 100 Propylthiouracil (generik)
mg
3 L-Tiroksin Nartrium Tablet 100 mg Thyrax, Euthyrox
16.4 KORIKOSTEROID DAN
KORTIKOTROPIN
1 Betametason + Desklofeniramin Maleat Tablet, Sirup Tablet 0,25 Celestamin Tablet, Syrup;
32
mg + 2 mg, Colergis Syrup; Ocuson Tablet

Syrup 0,25
mg + 2 mg
per 5ml
2 Deksametason Tablet, Injeksi Tablet 0,5 mg, Kalmethasone Injeksi 4 mg, 5
Injeksi 4 mg; Cortidex Injeksi 5 mg,
mg/ampul, 5 Tablet; Dexamethasone
mg/ampul Tablet, Injeksi 5 mg (generik)
3 Metilprednisolon asetat Tablet, Injeksi 4 mg, 8 mg, Lameson Tablet 4 mg, 8 mg, 16
16, inj 125 mg; Medixon Tablet, Injeksi;
mg/2 ml Hexilon Tablet 4 mg; Sanexon
Injeksi; Methylprednisolon
Tablet 4 mg, 8 mg, Injeksi
(generik)
4 Prednison Tablet 5 mg Pehacort; Prednison (generik)
5 Triamsinolon Asetonid Tablet, Injeksi, Tablet 4 mg, Triamcort Tablet; Trilac Tablet;
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Krim, Orabase, Injeksi IA/ID Kenacort Tablet; Flamicort

Semprot 10 mg/ml vial Injeksi; Kenacort A cream;
Hidung 5 ml, Krim Kenalog Orabase; Nasacort
0,1% (5 mg), Nasal Spray; Triamsinolon
Orabase 1% Tablet (generik)
16.5 HORMON LAIN
1 Bromokriptin Tablet 2,5 mg Cripsa
16.6 OBAT METABOLISME TULANG
DAN OTOT
33
1 Alendronat Tablet 10 mg Allovel

17 OBAT KARDIOVASKULAR
17.1 ANTIANGINA
1 Bisoprolol Tablet 2,5 mg, 5 mg Concor 2,5 mg, 5 mg; Maintate
2,5 mg, 5 mg; Bisoprolol 5 mg
(generik)
2 Diltiazem Tablet, Kapsul, Tablet 30 mg, Herbesser Tablet, CD 100, CD
Injeksi Kapsul 100 200, Injeksi; Diltiazem Tablet
mg, 200 mg; (generik)
Injeksi 50 mg
3 Isosorbid Dinitrat Tablet, Injeksi Tablet 5 mg, Cedocard Tablet; Farsorbid
Injeksi Injeksi; Isosorbiddinitat
10mg/10ml Tablet, Injeksi (generik)
4 Isosorbid Mononitrat Tablet 20 mg Cardismo
Ivabradin Tablet 5 mg Coralan
5 Trimetazidin Tablet 30 mg Trizedon MR
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
6 Nitrogliserin Kapsul 2,5 mg, 5 mg Nitrokaf Retard 2,5 mg, Retard

Forte 5 mg
17.2 ANTIDISRITMIA
1 Adenosin Injeksi, Tablet Injeksi 3 ATP Injeksi; Bio ATP Tablet;
mg/ml vial 2 ATP Dankos Tablet
ml, Tablet
2 Amiodaron Tablet, Injeksi Tablet 200 Cordaron
mg, Injeksi
150 mg/3ml
34
3 Propranolol HCl Tablet 10 mg, 40 mg Propranolol (generik)

4 Verapamil Tablet 80 mg Verapamil (generik)
17.3 ANTI HIPERTENSI
17.3.1 Golongan ACE Inhibitor
Imipril Tablet 5 mg Tanapres
1 Kaptopril Tablet 12,5 mg, 25 Captopril 12,5 mg, 25 mg
mg (generik)
2 Lisinopril Tablet 5 mg, 10 mg Noperten 5 mg, 10 mg;
Lisinopril 10 mg (generik)
3 Ramipril Tablet 2,5 mg, 5 mg Triatec 2,5 mg, 5 mg; Cardace
2,5 mg; Hyperil 2,5 mg, 5 mg;
Ramipril 5 mg (generik)
17.3.2 Golongan Beta Blocker
1 Bisoprolol Tablet 2,5 mg, 5 mg Concor 2,5 mg, 5 mg; Maintate
2,5 mg, 5 mg; Bisoprolol 5 mg
(generik)
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
2 Propranolol HCl Tablet 10 mg, 40 mg Propranolol (generik)

3 Karvedilol Tablet 6,25 mg V-Blok
17.3.3 Golongan Calcium Channel Blocker
1 Amlodipin Tablet 5 mg, 10 mg Divask 5 mg, 10 mg; Finevask
10 mg; Norvask 5 mg, 10 mg;
Amlodipin 5 mg, 10 mg
(generik)
2 Amlodipin + Telmisartan Tablet 5 mg + 40 Twynsta
mg, 5 mg +
35
80 mg
3 Amlodipin + Candesartan Tablet 5 mg + 8 mg Unisia
4 Diltiazem Tablet, Kapsul, Tablet 30 mg, Herbesser Tablet, CD 100, CD
Injeksi Kapsul 100 200, Injeksi; Diltiazem Tablet
mg, 200 mg; (generik)
Injeksi 50 mg
5 Nifedipin Tablet Tablet 5 mg, Adalat OROS 20 mg, 30 mg;
10 mg; OROS Nifedipine 10 mg (generik)
20 mg, 30 mg
6 Nikardipin Injeksi 1 mg/ml Blistra; Nicardipine (generik)
7 Nimodipin Tablet Salut, Tablet 30 mg, Nimotop Tablet, Ceremax
Larutan Infus, Lar Infus 10 Infus; Nimodipine Injeksi
Injeksi mg/50 mL, Inj (generik)
40 mg
8 Verapamil Tablet 80 mg Verapamil (generik)
17.3.4 Golongan Alpha Blocker
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
1 Terazosin HCL Tablet 1 mg, 2 mg Hytrin

17.3.5 Golongan Angiotensin II Antagonis
1 Irbesartan Tablet 150 mg, 300 Irbesartan (generik)
mg
2 Candesartan Tablet 8 mg, 16 mg Blopress; Candesartan
(generik)
3 Candesartan + Amlodipin Tablet 8 mg + 5 mg Unisia
4 Losartan Tablet 50 mg Angioten; Insaar; Losartan
(generik)
36
5 Telmisartan Tablet 40 mg, 80 mg Micardis

6 Telmisartan+ Amlodipin Tablet 40 mg + 5 Twynsta
mg, 80 mg +
5 mg
7 Valsartan Tablet 80 mg, 160 Diovan; Valsartan (generik)
mg
17.3.6 Golongan Lain-Lain
1 Klonidin HCL Tablet, Injeksi Tab 0,15 mg; Catapress Tablet, Injeksi;
Inj 0,15 Clonidin Tablet (generik)
mg/ml
2 Metildopa Anhidrat Tablet Salut 250 mg Dopamet
Selaput
17.4 GLIKOSIDA JANTUNG
1 Digoksin Tablet, Injeksi Tablet 0,25 Fargoxin Tablet, Injeksi;
mg, Injeksi Digoxin Tablet (generik)
0,25 mg/ml
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
17.5 OBAT UNTUK SYOK

17.5.1 Inotropik
1 Dobutamin Injeksi 250 mg/20 Dobuject; Dobutamin Guilini;
ml, 250 mg/5 Dobutamin (generik)
ml vial
2 Dopamin Injeksi 20 mg/ml Dopamin (generik)
(10ml)
17.5.2 Vasokontriktor
37

2 Efedrin HCL Injeksi Injeksi 50 Vasodrin 50 mg/ml; Ephedrine
mg/ml HCl, Injeksi 50 mg/ml
(generik)
3 Epinefrin HCL Injeksi 1 mg/ml Ephineprine (generik)
4 Norepineprin Bitartrat Injeksi 4 mg/4 ml Raivas; Norepinephrine
(generik)
17.6 PENURUN KOLESTEROL
1 Atorvastatin Tablet Salut 10 mg, 20 mg Fastor 20 mg; Lipitor 10 mg, 20
Selaput mg; Truvaz 10 mg, 20 mg;
Atorsan 10 mg; Atorvastatin
20 mg (generik)
2 Fenofibrat Kapsul 160 mg, 200 Lipanthyl Supra 160 mg, 200
mg, 300 mg mg, 300 mg; Lifen 200 mg;
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Trolip 300 mg; Fenofibrate

200 mg, 300 mg (generik)
3 Gemfibrozil Kapsul 300 mg Gemfibrozil 300 mg (generik)
4 Kolestiramin Powder 4 gram per Sequest
sachet
5 Pravastatin Tablet 20 mg Pravinat
6 Rosuvastatin Tablet 5 mg, 10 mg Crestor
7 Simvastatin Tablet 10 mg, 20 mg Stator, Simvastatin (generik)
17.7 VASODILATOR
38
1 Beraprost Tablet 20 mcg Dorner

2 Flunarizin Tablet 5 g, 10 mg Sibelium 5 mg; Flunarizine
5mg, 10 mg
3 Pentoksifilin Tablet, Injeksi Tablet 400 Trenal Tablet, Injeksi
mg, Injeksi
100 mg/5ml
4 Sildenafil Sitrat Tablet 50 mg, 100 Viagra 50 mg, 100 mg
mg
5 Siticolin Tablet, Injeksi Tablet 500 Beclov Injeksi; Brainact Tablet,
mg, Injeksi Citicholine Tablet, Injeksi
125 mg/ml 2 (generik)
ml ampul
6 Siticolin Sitrat + Sitidin Monofosfat + Kapsul 147,5mg + Memoran
Fosfaidil Serin 25% 121,5 mg +
125 mg
7 Tadalafil Tablet 5 mg, 10 mg Cialis OAD 5 mg, Cialis Tablet
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
10 mg
8 Vardenafil Tablet 10 mg, 20 mg Levitra
17.8 LAIN-LAIN
1 Ginko Biloba Tablet 40 mg Tebokan; Tanakan
2 Pirasetam Kaplet, Syrup, Kaplet 800 Neurotam Injeksi, Syrup;
Injeksi mg, 1200 mg; Piracetam Kaplet, Injeksi
Injeksi 1 (generik)
g/5ml, 3 g/5
ml; Syrup 500
39
mg/5ml
3 Piritinol Dihidroklorida Monohidrat Tablet, Syrup Tablet 100 Encephabol
mg, Syrup
100 mg/5 ml
18 OBAT TOPIKAL UNTUK KULIT
18.1 ANTIAKNE
1 Belerang Serbuk Sulfur
2 Triklosan Emulsi 2% 60 ml Phisohex
18.2 ANTIBAKTERI
1 Betametason Dipropionat + Gentamisin Krim 0,05% + 0,1% Diprogenta
2 Betametason Valerat + Gentamisin Krim 0,1% + 0,1% Celestoderm VG
3 Desonid + Neomisin Krim 0,05% + 0,5 Apolar – N
%
4 Framisetin Sulfat Kasa Steril 1% Lomattoel
5 Flusinolon Asetonid + Neomisin Krim 0,025% + Cinolon-N
0,5%
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
6 Fluprednidin-21-Asetat Krim 0,1% (10 Decoderm

gram)
7 Fluprednidin-21-Asetat + Gentamisin Krim 0,1% + 0,1% Gentacortin
(10 gram)
8 Fusidat Krim, Salep 2% 5 gram Fucidin
9 Fusidat (asam) + Betametason Valerat Krim 2% + 0,1 % Fucicort
10 Gentamisin Krim, Salep 0,1% Garamycin Krim, Salep;
Sagestam Krim; Gentamisin
Krim, Salep (generik)
40
11 Kloramfenikol Salep 2% Chloramfecort

12 Kloramfenikol + Hidrokortison Salep 2% + 2,5% Chloramfecort – H
13 Mupirosin Salep 2% Bactroban; Bactoderm;
Mupirocin (generik)
Neomisin + Bacitracin Salep, Powder 5 mg + 250 Nebacetin
IU per gram
14 Perak Sulfadiazin Krim 1% Burnazin
15 Ekstrak Plasenta + Neomisin Gel 10% + 0,5% Bioplacenton
18.3 ANTIFUNGI
1 Bifonazol Krim 1% Mycospor
2 Ketokonazol Krim, 2% Formyco Krim; Mycoral Krim;
Shampoo Ketomed SS; Ketokonazol
Krim (generik)
3 Klotrimazol Krim, Vaginal Krim 1%, Canesten Krim, SD Vaginal
Tablet Vaginal Tablet; Lotremin Krim
Tablet 500 mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
4 Klotrimazol + Deksametason Krim 1% + 0,04% Baycuten N

5 Mikonazol Nitrat Krim, Serbuk, 2% Funtas Krim; Daktarin Krim,
Oral Gel Oral gel, Powder; Mikonazol
Krim (generik)
6 Mikonazol Nitrat + Hidrokortison Krim 2% + 1% Thecort; Brentan
7 Nistatin + Zn Oksida Salep 100.000 IU + Myco-Z
200 mcg
8 Siklopiroks Larutan Kuku 80 mg/gram Loprox Nail Lacquer
(1,5 gram)
41
18.4 ANTIVIRUS
1 Asiklovir Krim 5% Zovirax; Acyclovir
18.5 ANTIINFLAMASI DAN
ANTIPRURITIK
1 Betametason Dipropionat Krim, Salep 0,05% Diprosone Krim, OV Krim, OV
Salep
2 Betametason Dipropionat + Asam Salep 0,05% + 2% Diprosalic
Salisilat
3 Betametason Valerat Krim 0,1% Benoson, CelestodermV
4 Deksosimetason Salep 0,25% 5 gram Esperson
5 Desonid Krim 0,05% (10 Apolar; Desolex
gram)
6 Flusinolon Asetonid Krim 0,025% (10 Cinolon
gram)
7 Hidrokortison Asetat Krim 1%, 2,5% Hydrocortison (generik)
8 Hidrokortison Butirat Krim, Lotion 1% Locoid Krim, Lotion,
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Lipocream
9 Kalamin Lotion, Bedak Lotion 15%; Caladine Lotion, Powder;
Bedak 10% Calamed Lotion
10 Klobetasol Propionat Krim, Salep 0,05% (10 Kloderma
gram)
11 Mometason Furoat Krim, Salep, 0,1% (5 gram, Mefurosan Krim 10 gram;
Lotion 10 gram, 20 Mufacort Krim 5 gram, Salep
ml) 10 gram; Elocon Krim 5 gram,
10 gram, Salep 5 gram, Lotion
42
20 ml
12 Prednikarbat Krim 0,25% (5 Dermatop
gram)
13 Triamsinolon Asetonid Krim, Orabase 0,1% Kenacort-A; Kenalog Orabase
18.6 ANTISKABIES
1 Permetrin Krim 5% 30 gram Scabimite
18.7 LAIN-LAIN
1 Alium cefa Extract Gel 10% (20 Mederma; Dermakel Gel, Kids
gram) Gel; Novell Smoothing Cream
2 Amfibilik Basa Krim Hipoalergenik Krim 20 gram Biocream
3 Asam Hialuronat Krim 0,2% (15 Bionect
gram)
4 Asam Salisilat Serbuk Acid Salicylic Pulv
5 Bedak Salisilat Bedak 2% Salycil Talk
6 Betaine + Biofilm + Polyhexanide Gel, Solution Gel (30 ml), Prontosan
Solution (350
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
ml)
7 Centella Asiatica Salep 1% (10 gram) Madecassol
8 Centella Asiatica + Vit E Krim 1% + 0,2% Lanakeloid-E
(10 gram)
9 Dimetikon + Vinil Dimetkon Gel (15 gram) Dermatix
10 Eco Honey + Gliserin + Propilen glikol + Gel (20 gram) Sanoskin Meladerm Plus
PEG 400
11 Ekstrak Camolmille Salep Kamilosan
12 Elastoregulator (lupeol dan Krim 150 gam Mustela
43
galatoarabinan) + Sophora japonica dan

oligo element + Sha Butter +Avocado
Peptide
13 Krim pH 5,5 Krim (200 ml) Sebamed Baby Cream
14 Lanolin Bahan Racikan Lanolin
15 Lanolin Anhidrous Krim (40 gram) Decubal
16 Minoksidil Larutan 2%, 5% (30 Regrou
ml)
17 Natrium Kokoil Isetionat Lotion (200 ml) Physiogel Lotion
18 O2 (dikonersi menjadi Ozone) + Minyak Gel (30 gram) Sanoskin Oxy
Zaitun
19 Oleat, Linoleat Trigliserid Krim (25 gram) Ezerra
20 Perak Nitrat Larutan 25% (30 ml) AgNO3 25% Solution
21 Pimekrolimus Krim 1% (10 gram) Elidel
22 Poliuretan Foam Foam 10 x 10 cm Sanoskin Foam
23 Psedodermal Lipid Krim (80 ml) Noroid Cream
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
24 Psedodermal Lipid + Zn Oksida Krim (60 ml) Noroid Derma Rash Cream
25 Radix Scutellariae + Phellodendri cortex Salep (20 gram) Sibro
+ Rhizoma Coptidis
26 Sabun untuk Kulit Sensitif Sabun Batang Sebamed Cleansing Bar for
Sabun Cair Baby, Sebamed Cleansing Bar
for Sensitive normal to oily
skin; CeraKlin Liquid Soap,
Soap Bar; Sovas Liquid Soap,
Soap Bar; Ceradan Body Wash,
44
Ceradan Cream; Lactacyd Baby

Blue
27 Urea Krim 10%, 20% (40 Carmed
gram)
28 Vaselin Bahan Racikan Vaselin Album
19 LARUTAN DIALISIS
1 Larutan Hemodialisa Larutan (100 ml) Renalin 100
20 LARUTAN ELEKTROLIT,
NUTRISI, DLL
20.1 ORAL
1 Asam Amino (Asam Keton) Tablet Aminoral; Ketosteril; Prorenal
2 Asam Amino (L-Glutamin) Tablet 1000 mg Glutrop
3 Kalium Klorida Serbuk, Tablet Tablet 600 mg KSR; KCl Pulv (generik)
4 Kalium-L-Aspartate Tablet 300 mg Aspar K
5 Kalium-L-Aspartate + Magnesium-L- Tablet 300 mg + 100 Renapar
Aspartate mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
6 Oralit Serbuk, 100 gram per Oralit KF Sachet; Pharolit

Larutan Sachet, Sachet; Renalyte Larutan
Larutan 200
ml
7 Ekstrak Monascus purpureus + Psidii Serbuk 4 gram per Trolit
Foium + Vitamin B kompleks + Zinc Sachet
20.2 PARENTERAL
1 Aqua pro Injeksi Larutan 25 mL, 100 WFI Otsuka; WI Widatra 1000
mL, 1000 mL ml
45
2 Asam Amino Infus Berbagai Aminosteril Infant 6%; Pan

komposisi Amin G; Kalbamin
3 Asam Amino + Vitamin + Elektrolit Infus Aminofusin L 600; Aminofusin
Pead
4 AsamAmino Rantai Cabang (BCAA) Infus Aminofusin Hepar; Comafusin
Hepar
5 Dextrose Infus 5%, 10%, Otsuka
40%
6 Kalium Klorida Injeksi 25 meq/ml Kalium Chloride
7 Kalsium Glukonat Injeksi 10% Calcii Gluconas
8 L-alanin + L-glutamin Infus Dipeptifen Infus
9 Larutan kombiasi (dalam 1 liter); Infus 500 ml Triofusin 500
fruktoka 60gram, glukosa 33 gram, silitol
30 gram
10 Larutan kombiasi (dalam 1 liter); Infus 500 ml Triofusin E 1000
fruktoka 120gram, glukosa 66 gram,
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
silitol 60 gram, elektrolit dan vitamin

11 Larutan kombiasi (dalam 1 liter); Infus 500 ml Triofusin 1600
fruktoka 200gram, glukosa 110 gram,
silitol 100 gram
12 Larutan kombinasi (dalam 1 liter); Infus 500 ml KA-EN 1B
natrium 38,5 mek, CL 38,5 mek, glukosa
37,5 gram
13 Larutan kombinasi (dalam 1 liter); Infus 500 ml Tridex
natrium 50 mek, K 20 mek, CL 20 mek,
46
laktat 20 mek glukosa 100 gram

14 Larutan kombinasi (dalam 1 liter); Infus 500 ml KAEN 3B; Tridex 27 A; Tridex
natrium 50 mek, K 20 mek, CL 50 mek, 27B
15 Larutan kombinasi (dalam 1 liter); Infus 500 ml KAEN 3A
natrium 60 mek, K 10 mek, CL 50 mek,
16 Larutan kombinasi : glukosa 10% dan Infus 500 ml Otsu D10
Natrium Klorida 0,9%= 4:1 (N5)
` 17 Larutan kombinasi : glukosa 2,5% dan Infus 500 ml Otsu D5 ½ NS
Natrium Klorida 0,45%
18 Larutan kombinasi : glukosa 5% dan Infus 500 ml Otsu D5 ¼ NS
19 Larutan kombinasi : glukosa 5% dan Infus 500 ml Otsu D5 ½ NS
20 Larutan kombinasi : glukosa 5%% dan Infus 500 ml Otsu D5 NS
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Natrium Klorida 0,9%= 4;1 (N4)

21 Larutan nutrisi+ elektrolit Infus Berbagai Clinimix; aminofluid
komposisi
22 Lipid Infus 20% Clinoleic
23 Maltose Infus 10% 500 mg Martos 10
24 Natrium bikarbonat Injeksi 8,4% vial 25 Meylon
ml
25 Natrium klorida Injeksi , infus Injeksi 0,9% NaCl Otsuka; NaCl Widatra;
20 ml; infus Ecosol; NaCl MJB
47
100ml,500
ml, 1000 ml;
3% 100 ml
26 Ringer asetat Infus Asering; Ring-As
27 Ring asetat + glukosa 50 gram Infus 500 mg Asering -5
28 Ringer laktat Infus 500ml, 1000 Ecosol-RL; Infusan RLDP; RL-
ml MJB; RL Otsuka; RL Widatra
21 OBAT UNTUK MATA
21.1 SISTEMIK
1 Asetazolamid Tablet 250 mg Glaucon
2 Manitol Injeksi 20% Manitol
21.2 TOPIKAL
21.2.1 Antimikroba
1 Gentamisin Tetes Mata/ Tetes Cendo Gentamisin ED, EO;
Tetes Telinga, Mata/Telinga Gentamisin EO (generik)
Salep Mata 3%, Salep
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Mata 3%
2 Kloramfenikol Tetes Mata Tetes mata Cendo Fennicol ED 0,25%,
Salep Mata; 0,25%, 0,5%, 0,5%, 1%, EO
1%, Salep
Mata 1%
3 Levofloksasin Tetes Mata 0,5% Cravit ED; Cendo FLX MD
4 Neomisin + Polimiksin + Deksametason Tetes Mata, Tetes mata Cendo Xitrol ED, EO; Cendo
Salep Mata 3,5 mg + Polydex ED; Polidemisin ED
60.000 IU +1
48
mg per ml,
Salep mata 5
mg + 60.000
IU + 1,3 mg
per gram
5 Neomisin Sulfat + Polimiksin B Sulfat + Tetes Mata 1,5 mg + Cendo Polygran ED
Gramisidin 10.000 IU +
0,025 mg per
ml
6 Ofloksasin Tetes Mata 0,3% Cendo Floxa MD, Tarivid ED
7 Tobramisin Tetes Mata 3 mg per ml Cendo Tobro ED
8 Tobramisin + Deksametason Tetes Mata 3 mg + 1 mg Cendo Tobroson MD
per ml
21.2.2 ANTI INFLAMASI
1 Diklofenak Natrium Tetes Mata 1 mg/ml Cendo Noncort MD
3 Fluorometolon + neomisin sulfat Tetes Mata (1 mg +3,5 Cendo Polynel ED
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
mg)/ml 0,6
ml; 5 ml
3 Klomoglikat natrium Tetes Mata 2% Cendo Conver ED
21.2.3 MIDRIATIK
1 Atropin Sulfat Tetes Mata 0,5 %; 1% Tropin ED 1%, Cendo Tropin
botol 5 ml ED 0,5%
2 Tropikamid Tetes Mata 1% Cendo mydriatyl ED
21.2.4 MIOTIK DAN ANTIGLAUKOMA
1 Pilokarpin Tetes Mata 2% Cendo Carpin ED
49
2 Latanoprost Tetes Mata 0,5% Glaopen MD

3 Timolol Tetes Mata 0,25%; 0,5% Cendo Timol ED
4 Timolol + Latanoprost Tetes Mata 0,25% + 0,5% Glauplus MD
21.2.5 LAIN LAIN
1 Gliserol Tetes Mata Opthalgon ED; Cendo Optalgon
ED
2 Hidroksi propil metil selulosa Tetes Mata 0,3% Tears naturalle II ED
3 Hidroksi Propil Metil Selulosa + Tetes Mata 5 mg + 0,25 Cendo Augentonic ED
Fenilefrin + Vitamin A mg + 1000 IU
per ml
4 Hialuronat Natrium Tetes Mata 0,1% Hyalid ED; Cendo Hyalub MD
5 Kalium Klorida + Kalium Iodida + Tetes Mata Cendo Catarlent ED
Natrium Tiosulfat
Kalium Iodida + Natrium Iodida Tetes Mata 5 mg + 10 mg Cendo Vitrolenta MD
per ml
6 Kalboksi Metil Selulosa Tetes Mata 5 mg per ml Cendo Cenfresh MD
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Nafazolin Tetes Mata 0,25 mg per Cendo Vernacel MD

ml
7 Natrium Klorida + Kalium Klorida Tetes Mata 8,664 mg + Cendo Lyteers ED
1,32 mg per
ml
8 Pemirolast Kalium Tetes Mata 0,1% Alegysal ED
Pirenoksin Tetes Mata 0,05 mg per Kary-Uni ED
ml (5ml)
9 Polivinil Pirolidon + Vitamin A + Na Tetes Mata Cendo Protagen A MD
50
Hialuronat + NaCl + Na Hidrogenfosfat

+ Na Dihidrogen Fospat
10 Tetera hidrozolin HCL Tetes Mata 0,05% (5 ml Visine ED, Insto ED
dan 10 ml)
11 Tetrakain HCL Tetes Mata 0,5%, 2% Pantocain ED
12 Vitamin A palmitat Salep Mata 10mg per ml Cendo Oculenta EO
22 UTEROTONIK DAN RELAKSAN
UTERUS
22.1 UTEROTONIK
1 Metilergometrin Maleat Tablet; Injeksi Tablet 0,125 Metvell Tablet, Injeksi;
mg, Injeksi Bledstop Tablet, Injeksi
0,2 mg/ml
2 Misoprostol Tab 200 mcg Cytotec; Gastrul
3 Oksitosin Injeksi 10 IU/ml Oxyla; Pitogin
22.2 RELAKSAN UTERUS
1 Isoksuprin HCL Tablet; injeksi Tablet 20 mg; Duvadilan Tablet, Injeksi;
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
injeksi 10 Hystolan Tablet; Proterin Tablet

mg/2 ml
ampul
2 Magnesium Sulfat Injeksi 20%; 40% Magnesium Sulphate
(generik)
3 Nifedipin Tablet Tablet 5 mg, Adalat Tablet 5 mg, 10 mg,
10 mg; OROS OROS 20 mg, 30 mg;
20 mg, 30 mg Nifedipine 10 mg (generik)
4 Terbutalin sulfat Tablet; injeksi 2,5 mg; Bricasma Tablet, Injeksi;
51
injeksi 0,5 Lasmalin Tablet

mg/ml
23 PSIKOFARMAKA
23.1 ANTIANSIETAS & ANTIINSOMNIA
1 Alpazolam Tablet 0,5mg, 1mg Alganax , Alprazolam 1 mg
(generik)
2 Diazepam Tablet, Syrup, Tablet 5 mg, Valisanbe Tablet, Injeksi;
Injeksi; Syrup 2 mg/5 Stesolid Syrup, Injeksi, Rectal
Larutan ml, Injeksi 10 tube 5 mg, 10 mg
Rektal, Sirup mg/2mL,
Larutan rektal
tube (2,5 mL)
5 mg, 10 mg
3 Estazolam Tablet 1mg, 2 mg Esilgan
4 Klobazam Tablet 10 mg Frisium
23.2 ANTIDEPRESI & ANTI MANIA
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
1 Amitriptilin HCL Tablet 25mg Amitriptilin HCL 25 mg

(generik)
3 Fluoksetin Kapsul 10 mg, 20 mg Kalxetin, Nopres
23.3 ANTIOBSESI & ANTIKOMPULSI
Metilfenidat HCl Tablet 10 mg Prohiper
23.4 ANTIPSIKOSIS
1 Haloperidol Tablet; Injeksi Tablet 5 mg, Haldol Tablet; Lodomer Injeksi;
Injeksi 5 Serenace Injeksi; Haloperidol
mg/ml tablet (generik)
52
2 Kloralhidrat Serbuk Chloralhydrat Pulv (generik)

3 Klorpromazin HCL Tablet Tablet 100 mg Chlorpromazin (generik)
4 Risperidon Tablet 2 mg Risperidon (generik)
5 Metil fenidat HCL Tablet 10 mg Prohiper 10
Inttermediet
Release
24 RELAKSAN OTOT PERIFER &
PENGHAMBAT KOLINESTERASE
24.1 PENGHAMBAT
NEUROMUSKULAR
1 Atracurium Injeksi 25mg/2,5ml Tracrium
2 Baklofen Tablet 10 mg Lioresal
3 Eperison HCL Tablet salut 50 mg Myonal; Eperison (generik)
selaput
4 Rokuronim Bromida Injeksi 50 mg Esmeron; Roculax
5 Tizanizin Tablet 2 mg Sirdalud
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
24.2 OBAT UNTUK MISTENIAGRAVIS

1 Neostigmin Metilsulfat Injeksi 0,5 mg/ mL Prostigmin; Neostigmin-
Hameln
25 OBAT UNTUK SALURAN CERNA
25.1 ANTASIDA & ULKUS, ANTIBUSA
1 Antasida DOEN Tablet, Syrup 500 mg Antasida DOEN Tablet,
Syrup (generik)
2 Alumunim Hidroksida + Magnesium Tablet, Syrup Mylanta Tablet, Syrup; polycrol
Hidroksida + Simetikon Syrup; Polysilane Tablet,
53
Syrup; Sanmag Syrup

3 Alumunim Hidroksida + Magnesium Tablet Sanmag Tablet
Hidroksida + Simetikon + Papaverine +
Kloriazepoksid + Vit B Kompleks
4 Dimetilpolisiloksan Tablet 40 mg Disflatyl
5 Esomeprazol Tablet, Injeksi Tablet 20 mg, Nexium Tablet, Injeksi
40 mg, Injeksi
40 mg per vial
6 Famotidin Tablet 40 mg Famocid
7 Fucoidan Tablet 50 mg, 100 Fucoidan
mg
8 Lansoprazol Kaspul 30 mg Prosogan FD; Lasgan ; Lancid,
Lapraz; Lagas; Lansoprazole
(generik)
9 Misoprostol Tablet 200 mcg Cytotec; Gasrul
10 Omeprazol Kapsul, Injeksi Kapsul 20 OMZ Kapsul, Injeksi; Pumpitor
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
mg; Injeksi 40 Kapsul, Injeksi; Protop Kapsul;

mg Rindopump injeksi;
Omeprazole Kapsul, Injeksi
(generik)
11 Pantoprazol Injeksi 40 mg Pepzol; Topazol; Pranza;
Pumpisel; Pantozol;
Pantoprazole (generik)
12 Rabeprazol Nartium Kapsul 20 mg Pariet
13 Ranitidin Tablet, Injeksi Tablet 150 Zantac tablet, Injeksi; Acran
54
; Syrup mg; Injeksi 25 Tablet, Injeksi; Rantin Tablet,

mg/mL ampul Injeksi; Ranicho Syrup, Ranivel
2 ml; Syrup Syrup; Ranitidin Tablet,
75 mg/5 mL Injeksi (generik)
14 Rebamipid Tablet 100 mg Mucosta, Rebamipid Tablet
(generik)
15 Sucralfat Tablet, Syrup Inpepsa Syrup; Episan Syrup;
Ulsafate Tablet, Syrup; Nucral
Syrup; Sucralfate Syrup
(generik)
25.2 ANTIEMETIK
1 Betahistin diHCl Tablet 8 mg, 24 mg Betaserc 8 mg, 24 mg
2 Betahistin Mesilat Tablet 6 mg, 12 mg, Merislon 6 mg, 12 mg;
8 mg, 24 mg Vertigosan tablet; Betahistine 6
mg (generik)
3 Dimenhidrinat Tablet 50 mg Dramamine; Antimo;
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Dimenhidrinat (generik)
4 Domperidon Tablet; Syrup; Tablet 10 mg; Motilium Tablet, Syrup;
Drop Sirup 1 mg/5 Vometa Tablet, Syrup, Drop;
ml; Drop 5 Dome Tablet, Syrup; Monell
mg/ml Syrup; Vomitas Tablet, Syrup;
Domperidon 5 Tablet, Syrup
(generik)
5 Granisetron Injeksi 1mg/mL Granon
6 Metoklopramid HCl Tablet , Syrup, Tablet 5 mg, Primperan Tablet, Sirup,
55
Injeksi 10 mg; Syrup Injeksi; Tomit Injeksi

5 mg/5 mL;
injeksi 10
mg/2 mL
7 Ondansetron HCl Tablet Salut Tablet 4 mg, 8 Trovensis Tablet 4mg, 8 mg,
Selaput; mg; Injeksi 4 Injeksi4 mg, 8 mg; Vomceran
Injeksi mg/2mL, 8 Tablet 8 mg, Injeksi, 8 mg;
mg/4 mL Vometron Syrup, Injeksi 8 mg;
Narfoz syrup; Cedantron Tablet
8 mg, Injeksi 4 mg, 8 mg;
Ondavel Tablet 4 mg, Injeksi 4
mg; ODR Injeksi 4 mg;
Ondansetron Tablet 8 mg,
Injeksi 4 mg , 8 mg (generik).
8 Piratiasin Teoklat + Vit B6 Tablet 40 mg + 37,5 Anvomer; Mediamer B6
mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
25.3 ANTIHEMOROID
1 Bismut Subgalat + Lidokain + Seng Suppositoria Antihemoroid (generik)
Oksida + Suppositoria
2 Fluokortolon Pivalat + Lidokain Cream, Cream 1 mg + Ultraproct N
supposioria 20 mg,
Suppositoria 1
mg + 40 mg
3 Hidrosmin Kapsul, Krim Kapsul 200 Venosmil
mg, Krim 20
56
mg
4 Diosmin + Hesperidin Tablet 450 mg + 50 Ardium
mg
5 Polikresulen + Sinkokain Suppositoria, 50 mg + 10 Faktu
Salep mg, 100 mg +
2,5 mg
25.4 ANTISPASMODIK
1 Atropin Sulfat Injeksi Injeksi 1 Atropine Sulfate (generik)
mg/mL
2 Hiosin N butil Tablet, Injeksi Tablet 10 mg, Buscopan Tablet, Injeksi;
Injeksi Spasmolit Tablet
20mg/mL
3 Hiosin N butil + Paracetamol Tablet 10 mg + 500 Buscopan Plus
mg
4 Klobazam Tablet 10 mg Frisium
5 Klordiazepoksid + Klidinium Tablet 5 mg + 2,5 Braxidin
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
mg
6 Alumunim hidroksida + magnesium Tablet Sanmag Tablet
hidroksida + simetikon + Papaverine +
Kloriazepoksid + Vit B Kompleks
25.5 OBAT UNTUK DIARE
1 Attalpugit Tablet 600 mg New Diatab
2 Garam Oralit Serbuk, 100 gram per Oralit KF Sachet; Pharolit
Larutan Sachet, Sachet; Renalyte Larutan 200
Larutan 200 ml
57
ml, 500 ml
3 Ekstrak Monascus purpureus + Psidii Serbuk 4 gram per Trolit
Foium + Vitamin B kompleks + Zinc Sachet
4 Loperamid HCl Tablet 2 mg Imodium
5 Smectit Serbuk 3g Smecta
6 Seng Sulfat Tablet Tablet 20 mg, Zinkid Sirup, Tablet; Zinkpro
Dispesiable, Sirup 20 mg/ Sirup, Drop; Orezink Sirup,
Sirup 5 mL, Drop Zanic Sirup, Zincare Tablet;
10 mg/ml Daryazink Drop; Interzinc
Tablet, Sirup; L-Zink Sirup
25.6 LAKSATIF
1 Bisakodil Tablet, Tab 5 mg; Dulcolax
suppositoria suppositoria
Pead 5 mg,
Adult 10 mg
2 Kombinasi; Na Lauril Sulfoasetat + Enema 45mg + 450 Microlax
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Natrium Sitrat + Asam Sorbat + PEG + mg + 5 mg +

Sorbitol 625 mg +
4465 mg per
mL
3 Kombinasi Sorbitol,Docusat Sodium Botol YAL
4 Laktulosa Sirup 3,335g/ 5 mL Lactulax ; Dulcolactol
5 Magnesium Sulfat Kristal 30 g Garam Inggris
6 Natrium Fospoda Enema Botol (133 Fleet enema (133 ml); Fosen
ml, 45 ml) (45 ml)
58
7 Parafin + Gliserin Sirup Fenolftalein Laxadine

55 mg;
Paraffin Liq
1,2 gram;
Gliserin 378
mg
8 Picosulfat Drop 7,5 mg/ml Laxoberon
25.7 LAIN – LAIN
1 Asam Ursodeoksikholat Kapsul 250 mg Urdafalk; Asam
Ursodeoksikholat (geneerik)
2 Cisaprid Tablet 5 mg Acpulsif; Pridesia
3 Curcumin Tablet 200 mg Curcuma
4 Glicirrhyzin Inj 40 mg amp 20 Stronger Neo-Minophagen C
mL
5 Kombinasi Enzim Saluran Cerna Dragee Enzyplex; Vitazym
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
6 Lactobacillus acidophilus Serbuk Lacto-B; Hexbio; L-Bio;

Liprolac; Probi; Protexin Infant,
Capsul
7 Lactobacillus helveticus Serbuk Probiokid
8 Lactobacillus reuteri Drop Interlac drop
9 Lactobacillus sporogenes Tablet Lacbon
10 Co Enzim B12 Kapsul 1000 mcg, Cobazym
3000 mcg
11 L-Ornitin L-aspartat Sachet, injeksi Sachet 3 g, Hepa-Merz
59
Injeksi 5 g/10
mL amp
12 Mesalazin Tablet Tablet 500 mg Salofalk
13 Silymarin (Ekstrak Silybum marianum) Kapsul; Syrup Berbagai Hepamax Kapsul; Hepasil
+ Ekstrak Curcuma xanthorrhizae Komposisi Kapsul; Hepa-Q Kapsul;
(Curcumin) + (lain2: Oleum Sanfuliq Kapsul; Curliv Syrup;
Xanthorrizae, Ekstrak Schizandrae, Bio-Curliv Kapsul
Ekstrak Echinacea, Vit E, PPC)
14 Schisandrin (Ekstrak Schizandrae Kapsul 7,5 mg Hp-Pro
Ftructus)
15 Ekstrak radix salvia milthiorizza + Serbuk Sachet 140 AHFC (Antihepatic Fibrosis
Ekstrak astragalus membranaceus + gram Cirosis)
radix bupleurum chinense + Ekstrak
radix spatholobus suberectus
26 OBAT UNTUK SALURAN NAFAS
26.1 ANTIASMA
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
1 Aminofilin Tablet; Injeksi Tablet 200 Aminophyllin tablet 200 mg;

mg; Injeksi 24 injeksi (generik)
mg/mL
2 Flutikason Furoate Semprot Semprot Avamys 120 Nasal Spray;
Hidung, Hidung 27,5 Flixotide Nebule
Nebules mcg, Nebules
0,5 mg
3 Budesonid Inhaler 0,25 mg/ml Pulmicort
4 Budesonid + Fomoterol Inhaler 80/4,5 mcg, Symbicort
60
160/4,5 mcg
6 Efedrin HCl Injeksi Injeksi 50 Vasodrin 50 mg/ml; Ephedrine
mg/ml HCl Injeksi 50 mg/ml
(generik)
7 Epinefrin Injeksi 0,1% Epinephrine HCl (generik)
8 Flutikason propionat Nebule Nebules 0,5 Flixotide
mg/2ml
9 Indakaterol Inhaler 300 mg per Onbrez
kapsul
10 Ipratropium bromida inhalasi 20 mcg/spray Atrovent
11 Ketotifen Tablet 1 mg Profilas
12 Klenbuterol HCl Tablet 20 mcg Spiropent
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
13 Prokaterol HCl Hemihidrat Mini Tablet; Tablet Mini Meptin Tablet Mini, Tablet,
Tablet; Syrup; 25 mcg, Syrup, Inhalasion Sol, Ataroc
Nebule, Tablet 50 Sirup
Inhaler mcg, Syrup
25 mcg/5ml,
Nebule 100
mcg/0,3 ml,
Inhaler 10
mcg/puff
61
14 Salbutamol Tablet, Syrup, Tablet 2 mg, 4 Ventolin Tablet 2 mg, Syrup,

Inhaler, mg, Syrup 2 Nebules, Inhaler; Velutine
Nebules mg/5ml; Nebules; Fartolin Nebules;
Inhaler 100 Astharol Tablet 4 mg, Syrup
mcg/puff; Salbutamol Tablet (generik)
Nebules 2,5
mg
15 Salbutamol + GG Sirup 1 mg + 50 mg Ventolin exp
16 Salbutamol + Ipratropium Bromida UDV Nebules 2,5 mg + 0,5 Combivent UDV
mg UDV
17 Salmoterol + Flutikason Propionat MDI Inhaler; MDI 25 mcg Seretide MDI 50, MDI 125,
Diskus + 50 mcg Diskus 250 mg, Diskus 500;
/puff, 25 mcg Flutias MDI 50, MDI 125
+ 125 mcg
/puff (120
dosis), Diskus
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
50 mcg + 250
mcg/ puff, 50
mcg + 500
mcg /puff
(120 dosis)
18 Teofillin Tablet; Serbuk Tablet 150 Teobron Tablet; Teofillin pulv
mg, Tablet SR
300 mg
19 Terbutalin sulfat Tablet; injeksi 2,5 mg; Bricasma Tablet, Injeksi;
62
injeksi 0,5 Lasmalin Tablet

mg/ml
20 Tiotropium Inhaler + Handihaler + Spiriva Combo
Kapsul Kapsul 18
mcg
26.2 ANTITUSIF
1 Dekstrometorfan HBr + Doskilamin Syrup 5 mg + 2 mg Vicks Formula 44 Dewasa
per 5 ml
2 Dekstrometorfan HBr + Guaifenesin Syrup 3,5 mg + 50 Vicks Formula 44 Anak-Anak
mg per 5 ml
3 Kodein HCl/Fosfat Tablet 20 mg Codikaf; Kodein Kimia Farma
(generik)
4 Kodein + Feniltolokamin Kapsul, Syrup Kapsul 30 mg Codipront
+ 10 mg,
Syrup 11,11
mg + 3,67 mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
per 5 ml
5 Levodropropizine Syrup 60 mg/10 ml Levopront Syrup
6 Noskapin Drop , kapsul Drop 10 Mercotin drop; Longatin kapsul
mg/ml, kap 25 25 mg, 50 mg
mg, 50 mg
26.3 MUKOLITIK
1 Ambroksol Tablet, Sryup, Tablet 30 mg, Mucopect Tablet, Drop 7,5
Drop Drop mg/ml, Syrup Pead 15 mg/5 ml,
7,5mg/ml, Syrup Forte 30 mg/5ml, Epexol
63
Drop 15 Tablet, Drop 7,5mg/ml, Syrup

mg/ml, Syrup 15 mg/5 ml, Syrup Forte 30
15 mg/5ml, mg/5ml; Mucera Drop
Syrup 30 15mg/ml, Ambroxol Tablet,
mg/5ml Syrup 15mg/5ml (generik)
2 Bromheksin Injeksi, Tablet, Tablet 8 mg, Bisolvon
Eliksir, Eliksir
Larutan 4mg/5ml,
Larutan
2mg/5ml,
Injeksi
2mg/ml
3 Erdostein Kapsul, Syrup 300 mg, Vestein Kapsul, Syrup;
Syrup Vectrine Kapsul, Syrup;
175mg/5ml Medistein Kapsul; Erdostein
Kapsul (generik)
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
4 Karbostein Kapsul, Syrup Kaspsul 375 Rhinathiol

mg, Syrup
100 mg/ 5ml
5 N-Asetilsistein Serbuk, Serbuk 100 Fluimucyl Serbuk 100 mg, 200
Kapsul, Tablet mg, 200 mg mg, Kapsul, Syrup, Injeksi;
Effervescent, Kapsul 200 Hidonac Injeksi; Pectocil Kasul;
Sirup, Injeksi mg, Tablet Acetin Tablet Effervescent; N-
Effervescent Asetil sistein Kapsul (generik)
600 mg, Sirup
64
150 mg/5 mL,

Injeksi 300
mg/3ml
26.4 EKSPEKTORAN
1 Ekstrak Daun Ivy + Larutan Sorbitol K Syrup *ekstrak ivy Prospan
Sorbate + Citric Acid 0.7 g
2 Ekstrak thymi herba + pimulae radix, Syrup Silex Batuk, Pilek
althaeae folium + droserae + serphylli
herba
3 Guaifenesin + Oksomemasin Syrup 33,3 mg + Comtusi; Zemindo; Toplexil
1,65 mg per 5
ml
4 Amonium Klorida + Guaifenesin + Syrup 100 mg + 30 Sanadryl
Difenhidramin HCl + Na Sitrat + Mentol mg + 12,5 mg
+ 50 mg + 1
mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
5 Kodein + Feniltolokamin + Guaifenesin Kapsul, Syrup Kapsul 30 mg Codipront Cum Expectorant

+ 10 mg +
100 mg,
Syrup 11,11
mg + 3,67 mg
+ 55,55 mg
per 5 ml
6 Obat Batuk Hitam (Succus Glycyrrhizae Syrup OBH Combi Batuk, pilek
NH4Cl) + Klorfeniramin Maleat +
65
Efedrin
7 Obat Batuk Hitam (Succus Glycyrrhizae Syrup OBH Nelco Batuk, pilek,
dan demam
NH4Cl) + Klorfeniramin Maleat +
Efedrin + Paracetamol
8 Pipazetahte HCL, Isothipendyl HCL, Syrup 10 mg + 2 mg Transpulmin
Ekstrak Liquorice + Guaifenesin + 50mg +
25mg
26.5 LAIN-LAIN
1 Beractant Injeksi 25 mg/mL Survanta
2 Lisat Bakteri untuk infeksi saluran Kaspul 3,5 mg Broncho-Vaxom
pernafasan
SISTEM IMUN
27.1 SERUM & IMUNOGLOBULIN
1 Anti Rho (D) gama Globulin Injeksi 300 mcg vial Hyperrho-D
2 Gama globulin imun Injeksi 5% Gammaraas
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
3 Serum Anti tetanus Injeksi 1500 iu ATS

4 Tetanus Imun Globulin Injeksi 250 iu Tetagam P
27.2 VAKSIN Injeksi
1 Vaksin Anti Polio Injeksi 40 Antigen Vaksin Polio Biofarma (Dinkes)
Unit (Tipe 1);
4 Antigen unit
(Tipe 2); 32
Antigen unit
(Tipe 3)
66
2 Vaksin BCG Injeksi 2 ml; 4 ml Vaksin BCG (Dinkes)

3 Vaksin Campak Injeksi 5 ml Vaksin Campak (Dinkes)
4 Vaksin Difteri dan Tetanus Injeksi 5 ml Ampul DT Dinkes
5 Vaksin Difteri pertussis dan Tetanus Injeksi 5 ml Infanrix; Tripacel; DPT Dinkes
6 Vaksin Hepatitis A Injeksi 720 IU/ml Havrix 720 Junior
7 Vaksin Hepatitis B Injeksi 100 mcg/0,5 Engerix, Eufax; Hepatitis B
ml, 20 Single dose Dinkes
mcg/0,5 ml
Vial
8 Vaksin HPV Injeksi Gardasil, Cervarix
9 Vaksin IgG Hepatitis B Injeksi 217 IU/ml Hyperhep-B
10 Vaksin Influenza Injeksi 0,25 ml; 0,5 Vaxigrip, Imovaxigrip
ml
11 Vaksin Kombinasi DPaT-Hib Injeksi 0,5 ml Infanrix-Hib; Tetract-HIB
12 Vaksin Kombinasi DPT, HIB, Polio, Injeksi Hexaxim
Hepatitis B
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
13 Vaksin Kombinasi DPT, HIB, Polio Injeksi 0,5 ml Pediacel

14 Vaksin MMR Injeksi 0,5 ml Trimovax
15 Vaksin Pneumokokus Inj 0,5 ml Prevenar; Synflorix
16 Vaksin PPD Inj 2 UT 1,5 ml Vaksin PPD
17 Vaksin Rotavirus Inj Rotarix, Rotatex
18 Vaksin Typoid Inj 0,5 ml Typhim; Typherix
19 Vaksin TT Inj Vial 5 ml, 10 Vaksin TT, Jerap Tetanus
ml; Uniject
0,5 ml
67
20 Vaksin Parisela Inj 0,5 ml Vial Varilrix

28 OBAT UNTUK TELINGA HIDUNG
& TENGGOROKAN
28.1 ANTIBAKTERI TOPIKAL
1 Fradiomisin + Gramisidin Tablet Hisap 2,5 mg + 1 FG Troches
mg
2 Kloramfenikol + Polimiksin B SO4 Tetes Telinga 5% + 10.000 Otolin, Otilon
IU
3 Ofloksasin Tetes Telinga 3 mg/mL (5 Tarivid Otic Drop; Akilen
mL)
4 Polimiksin + Neomisin + Betametason + Tetes Telinga 10.000 IU + 5 Otozambon
Lidokain mg + 1mg +
40 mg
5 Polimiksin + Neoomisin + Tetes Telinga 10.000 IU + 5 Otopain
Fludrocortison, Lidokain mg + 1mg +
40 mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
28.2 LAIN-LAIN
1 Flutikason Furoat Semprot 27,5 Avamys
Hidung mcg/Semprot
2 Karbo gliserin Tetes Telinga 10% Karbo gliserin 30 mL
(generik)
3 Larutan Air Laut Isotonis Semprot Sterimar Baby; Aqua Maris
Hidung, Tetes Nasal Spray, Nasal Drop
Hidung
4 Mometason Furoat Semprot 50 mcg/dosis Nasonex
68
Hidung
5 Natrium Dukosat Tetes Telinga 5 mg/ml Forumen
6 Natrium Klorida Tetes Hidung 6,5 mg/ml Breathy Nasal Drop
7 Oksimetazolin HCl Semprot 0,05%, Afrin; Illiadin
Hidung, Tetes 0,025% (Tetes
Hidung Hidung Paed),
Dewasa, Tetes 1%
Hidung Paed
8 Perak Nitrat Larutan 25% (30 ml) AgNO3 25% Solution
9 Triamsinolon Asetonid Semprot 55 mcg/dosis Nasacort AQ
Hidung
29 VITAMIN & MINERAL
1 Fluorida (Natrium) Tablet 1 mg Vinafluor
2 Kalsitriol Kapsul lunak 0,25 mcg, 0,5 Oscal 0,25 mcg, 0,05 mcg;
mcg Ostovell 0,5 mcg; Kolkatriol
0,5 mcg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
3 Asam Folat Tablet 400 mcg, Folavit 400 mcg, 1000 mcg;
1000 mcg, 5 Folarin 1000 mcg; Asam Folat
mg 1 mg, 5 mg (generik)
4 Besi Sukrosa Injeksi 100 mg/5 ml Venofer
5 Besi (II) dlm bentuk garam sulfat, Tablet, Sirup, Kombinasi Emineton Tablet; Hemobion
fumarat Drop Tablet; Ferofort Tablet;
Sangobion Tablet, Sirup, Drop;
Ferriz Sirup, Drop; Ferlin Drop
6 Kompleks Besi (III) Hidroksida Tablet, Sirup, Tablet 357 mg Maltofer Fol Chewable Tablet,
69
Polimaltose (IPC) + Asam Folat + 350 mcg Sirup

7 Kalium Klorida Serbuk, Tablet Tablet 600 mg KSR; KCl Pulv (generik)
8 Kalium-L-Aspartate Tablet 300 mg Aspar K
9 Kalsium Hidrogen fosfat + Tablet 500 mg +133 Cavit D3; Calvit D
Kolekalsiferol IU
10 Kalsium Glukonat Injeksi 100 mg/ml Calcii Gluconas (generik)
11 Kalsium Karbonat Capsul 500 mg CaCO3 (generik)
12 Kalsium Karbonat + Vit D3 + Vitamin Tablet *Ca 300 mg Elkana Tablet; Lycavit Tablet
B6
13 Kalsium Karbonat + Vit D3 + Mineral Tablet *Ca 600 mg + Obical
Mg, Zn, Co, Mn, Bo 200 IU
14 Kalsium Karbonat + Isoflavon +Vit D3 + Tablet *Ca 500 mg Cal-95, Eazycal
Vit K1 + Mineral Mg, Zn, Bo
15 Kalsium Laktat /fosfat Tablet 500 mg Kalk (generik)
16 Kalsium Organic Aquamin Tablet 400 mg Calnic Plus
17 Kalsium + Vitamin D3 + Mineral Mg, Tablet, Syrup Tablet *Ca Osteocare Tablet, Syrup;
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
Zn, Mn 300 mg, Epocaldi Tablet

Syrup *Ca
150mg/5ml
18 Kalsium + Vitamin Tablet CDR; CDR Fortos; Redoxon
Effervescent
19 Ossein Hidroksiapatit Tablet 200 mg, 800 Ossoral 200 mg, 800mg
mg
20 Kombinasi Betakaroten + Vit C + Vit E Tablet Seloxy
+ Zn + Se
70
21 Kombinasi Betakaroten + Vit C + Vit E Tablet Seloxy AA

+ Zn + Se + alpha lipoic acid
22 Vitamin A Kapsul Lunak 6.000 IU, Vitamin A (generik)
20.000 IU
23 Vitamin B1 (Tiamin HCl) Tablet 50 mg, 100 Vitamin B1 (generik)
mg
24 Tiamin Tetrahidrofurfuril Disulfid Tablet Tablet 5 mg, Alinamin-F
25 Vitamin B6 (Piridoksin) Tablet 10 mg Vitamin B6 (generik)
26 Vitamin B6 + Asam Folat Tablet Vomilat
27 Vitamin B6 + Vitamin B12 + Asam Tablet Forneuro
Folat + Vitamin E
28 Vitamin B12 (sianokobalamin) Tablet 50 mcg Vitamin B12 (generik)
29 Vitamin B12 + Ekstrak Plasenta Tablet 20mcg +15 Moloco B12, Lactafit
mg
30 Mekobalamin Kapsul, Injeksi Kapsul 500 Methycobalt Kapsul, Injeksi;
mcg, Injkesi Lapibal Kapsul; Mecobalamin
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
500 mcg/ml Kapsul, Injeksi (generik)

31 Kombinasi Vitamin B Tablet, Injeksi Berbagai Neurobion Tablet, Neurobion
Komposisi 5000 Tablet, Injeksi;
Neurosanbe Tablet, Injeksi,
Becombion Syrup, drop; Ferlin
Drop; Sanbe-B-Plex Drop;
Sanvita Syrup; Becombion
+Lysine Syrup; Vitamin B
kompleks (generik)
71
32 Vitamin B komplek + Vitamin E Tablet Fundamin-E

33 Vitamin C (Asam Askorbat) Tablet, Injeksi Tablet 100 Extrace Injeksi 100mg/ml,
mg, 300 mg, Vitacimin 500 mg, Cester
500 mg, Tablet 300 mg; Sankorbin
Injeksi 100 injeksi 200mg/ml Vitamin C
mg/mL 2ml 100 mg (Generik)
ampul, 200
mg/ml 5ml
ampul
34 Vitamin C + Zn Syrup; Drop Imunped
35 Vitamin C + Vitamin B kompleks Tablet, Syrup Tablet *Vit C Enervon-C Tablet, Syrup;
500 mg, Becom C Tablet, Subex- T
Syrup *Vit C Tablet
83,33 mg/5ml
36 Vitamin C + Vitamin B kompleks + Tablet Subex-Z
Vitamin E +Mineral dan Asam Folat
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
37 Vitamin E (tokoferol) Tablet 100 IU, 400 Santa E 100 IU; Eturol 400 IU.
IU
38 Vitamin K1 Injeksi 2 mg/ml Prohem; Neo-K; Vitadion;
(Phytomenadione/phytonadione) Phytomenadione (generik)
39 Vitamin K3 (Menadione) Injeksi Vitamin K3 (generik)
40 Multivitamin Injeksi Injeksi Vial 5ml Cernevit
41 Multivitamin + lysine Syrup Zamel Drop, Syrup; Apialis
drop; Becombion+Lysine Syrup
42 Multivitamin + Mineral Tablet Theragran M; Biosanbe; Inbion;
72
Zegafit
43 Multivitamin + Mineral + Kalsium Syrup Elkana
44 Multivitamin + Mineral + Asam Folat Kapsul Obimin AF; Elevit; Folamil;
untuk Kehamilan dan Menyusui Prenamia; Vitamam 1, 2, 3
45 Multivitamin + Mineral + Asam Folat + Kapsul, Syrup Obipluz Kapsul; Osfit DHA
DHA untuk Kehamilan dan Menyusui Kapsul; Elkana-CL Emulsion;
Folamil Genio Kapsul; Folda
Kapsul; Lactafar; Prenatin DF;
Prohelic; Promavit;
SALURAN KEMIH
30.1 ALPHA BLOCKER
1 Tamsulosin Tablet 0,2 mg, 0,4 Harnal-D, Halnal OCAS
mg
30.2 5 ALPHA REDUCTASE INHIBITOR
1 Dutasterid Tablet 0,5 mg Avodart
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
2 Finasterid Tablet 5 mg Prostacom

30.3 ANTISEPTIK
Asam Nalidiksit Tablet 500 mg Urineg
1 Asam Pipemidat Kapsul 400 mg Urinter, Urotractin
30.4 PARASIMPATOMIMETIK
1 Distigmin Bromidum Tablet 5 mg Ubretid
2 Flavoksat HCl Tablet 200 mg Urispas
31 LAIN-LAIN
1 Asam Hialuronat Injeksi 20 mg/ml Durolane; Guardix
73
2 Astaxantin Tablet 4 mg Asthin Force; Xidane

3 Astaxantin + Selenium Tablet 4 mg +15 mg Astaplus; Matovit AX
4 Biostrum + (Vitamin + Mineral) Syrup *Biostrum Biostrum; Vistrum
300 mg
5 DHA/EPA Minyak ikan + (Vitamin E, Kapsul Nulacta; Inlacta; Prolacta For
Peppermint) mother; Prolacta For Baby;
Vibrion
6 Cod Liver Oil + Vitamin + Mineral + Syrup Scott Emulsion
Asam Amino
7 Ekstrak Billberry + Betakaroten + Tablet, Syrup Tablet 80 mg Matovit Tablet, Syrup
Vitamin A + Vitamin E + 5 mg +
1.600 IU + 40
IU, Syrup 40
mg +2,5 mg +
800 IU + 20
IU per 5 ml
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
8 Ekstrak Cranberry + Vit C + Kapsul 375 mg + 60 Prive Uri-Cran

Lactobacillus Achidopillus + mg + 0.1 mg
Bifidobacterium bifidum + 0.1 mg
9 Ekstrak Cucumis melo (SOD: Super Kaspul 250 IU Glisodin
Oksida Dismutase) + Gliadin
10 Ekstrak Curcuma Tablet Curcuma Tablet
11 Ekstrak Curcuma + Vitamin B + Syrup Curcuma Plus; Vitacur
Betakaroten
12 Ekstrak Curcuma + Vitamin B + Lysine Syrup Likurmin
74
13 Ekstrak Curcuma + Vitamin B + Tablet, Syrup Curvit

Betakaroten + Kalsium
14 Ekstrak Curcuma + Multivitamin A,B,D Syrup Curmunos
+ Mineral + DHA + Colostrum + Lysine
15 Ekstrak Curcuma + Multivitamin A,B,D Syrup Culvit CL-Emulsion
+ Mineral + DHA
16 Ekstrak Echinacea + Zn picolinate Tablet, Syrup Imboost Tablet, Syrup; Imunos
Syrup
17 Ekstrak Lagerstroemia speciosa Folium Tablet 100 mg Inlacin
+ Cinnamomum burmannii Korteks
18 Ekstrak Ophiocephalus striatus Kapsul 500 mg Vip-Albumin
19 Ekstrak Phaleria macrocarpa Tablet 100 mg Dismeno
20 Ekstrak Phyllanthus nururi Herba + Tablet, Syrup Tablet 50 mg Divens; Stimuno Syrup
Nigel sativa Semen + 360 mg, 50
mg + 360 mg
per 5 ml
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
21 Ekstrak Phyllanthus niruri + Echinacea Tablet, Syrup Tablet 50 mg Formuno Tablet; Imboost Force
purpurea + Black elderberry + Zn + 250 mg + Tablet; Syrup; Starmuno Tablet
picolinate + vitamin C 300 mg + 10
mg + 100 mg,
Syrup 50 mg
+ 250 mg +
100 mg per 5
ml
22 Ekstrak Phyllanthus niruri + Ekstrak Tablet 50 mg + 200 Imudator
75
Polinace + Zn picolinate + Ekstrak reisi mg + 10 mg +

mushroom 250 mg
23 Ekstrak Pygeum Africanum + Vitamin Kapsul Extrak 100 Torrex
dan Mineral + Asam Folat mg
24 Ekstrak Red Clover (isoflavone) Tablet 40 mg Promeno
25 Ekstrak Rhizoma paridi Kapsul 140 mg Ewoma
26 Ekstrak Sericocalyx folium + Kapsul 21.4%21.4%, Renax
orthosiphonis herba + sonchus folium + 17.85%,
plantago folium 7.15%
27 Ekstrak Tribulus terrestris Tablet 250 mg Biosane 250 mg
28 Ekstrak Trigonella foenum-graecum, Tablet 600 mg + 100 Lactamor; Lactamam
ekstrak Sauropus androgynous + vitamin mg + 20 mcg
B12 + Calsium Phosphate Dibasic + 12 mg
29 Ekstrak Vaccinium myrtillus fructus + Tablet 80mg + Vitanorm
Ekstrak Calendula officinalis flos + 36,10mg +
Ekstrak helenium autumnale flos 12,09mg
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
30 Siticolin Sitrat + Sitidin Monofosfat + Kapsul 147,5mg + Memoran

Fosfaidil Serin 25% 121,5 mg +
125 mg
31 Glukosamin Tablet, Krim Tablet 250 Mediflex Krim; Glucosamine
mg, Krim (75 Tablet (generik)
gram)
32 Glucosamin + Kondroitin Kaplet, Tablet Kaplet 500 Oste Forte Kaplet; Effervescent;
Effervescent, mg + 400 mg Osmetin Zuper Sachet;
Krim Tablet Flexamin Cream
76
Effervescent
750 mg + 500
mg, Krim (15
gram, 30
gram)
33 Heptapeptida untuk Stroke Tetes Hidung methionil- Semax
glutamil-
histidil-
phenylalanil-
prolil-glycil-
proline 0,1 %
34 Lactobacillus rhamnosus + Lactobacillus Tablet 2.5 x 109 Floragyn
reuteri CFU + 2.5 x
109 CFU
35 Lactoserum lactic acid pH 3-4 Sabun; Gel Lactacyd Woman Pink; Prodiva
Gel
NO. NO.
BENTUK KETE-
SEDIAAN RANGAN
TERAPI OBAT
36 Lesitin + Vitamin B kompleks + Vitamin Kaspul 300 mg Lesichol

E (lesitin)
37 Lubricant Jelly KY Jelly
38 Kolagen Tablet, Serbuk B-Gen Sachet
39 Oleum Eucalyptol + Chamomile Balsam 10 % + 0,2% Transpulmin BB
concentrate
40 Oleum Eucalyptol + Chamomile Balsam 10 % + 0,2% Transpulmin
concentrate + Mentol + Camphor + 5% +2,5 %
41 Oleum eucalyptus, cajuput oil, clove oil, Softgel 44,315 mg + Vaporin
77
juniper oil, levomenthol, peppermint oil, 23,125 mg +

methyl salicylate 0,125 mg +
3,375 mg +
5,125 mg +
44,315 mg +
4,625 mg
42 Ragi (Plasmolyset Herbal Yeast) Syrup; Tablet 80% Bio-Starth
43 Ubiquinon Kapsul lunak 100 mg Q-ten; Coten
45 Ubiquinon + L-Karnitin Kapsul Lunak 30 mg + 500 Car-Q
mg
46 Ubiquinon + L-Karnitin + Vit E + Asam Kapsul Lunak Berbagai Tonicard
Folat Kobinasi
47 Ubiquinon + Lycopene + Vit E + Ekstrak Kapsul Lunak Bebagai Liproqy
Greap Seed, Ekstrak Green tea Kombinasi

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DAFTAR OBAT FORMULARIUM RUMAH SAKIT HERMINA DAAN MOGOT BERDASARKAN KELAS TERAPI

3 Morfin HCl Injeksi 10 mg/mL Morphine HCl KF

9 Etorikoksib Tablet 90 mg, 120 Arcoxia

Suppositoria 100 mg, CR Suppositoria; Pronalges Tablet,

14 Metil Salisilat Krim, Larutan Krim (30 Counterpain Krim; Gandapura

Drop Syrup 120 mg/5ml; Tempra

18 Parasetamol + Vit B Kompleks Tablet 500 mg + B1 Dolo-Neurobion

4 Lidokain HCl + Prilokain Krim 25 mg + 25 Dolones

1 Brompheniramin maleat + Pseudoefedrin Sirup 2 mg + 30 mg Alco Plus DMP

14 Klorfeniramin Maleat Tablet 4 mg Pehaclor, Alleron,

19 Loratadin Tablet, Sirup Tablet 10 mg, Claritin Tablet, Syrup; Alloris

26 Setirizin Tablet, Sirup, Tablet 10 mg, Cerini Tablet, Sirup, Drop;

Inj 8,4% Bikarbonat Tablet (generik)

2 Fenitoin Natrium Kapsul, Injeksi Kapsul 100 Ikaphen Injeksi; Dilantin

2. Pirantel Pamoat Tablet, Tablet 250 Combantrin

3 Ampisilin Tablet 500 mg Ampisillin (generik)

3 Siprofloksasin Tablet, Infus Tablet 500 Baquinor Forte Tablet, Infus,;

mg, Sirup 500 mg; Zithrax Tablet 500 mg;

4 Roksitromisin Tablet 150 mg Uplores

mg/mL, 250 mg/5 ml, Drop; Qidrox Kapsul

mg/5 mL sirup kering; Anfix Kapsul 100

gram, 3 gram Monuril sachet 3 gram;

Syrup 125 Metronidazole Tablet Forte,

mg, Infus (generik)

500.000 IU; Drop; Constantia Drop; Nymico

6 Valasiklovir Tablet 500 mg Herclov

5 Sinarin Tablet 25 mg Stugeron

6 Klopidogrel Tablet 75 mg Plavix; CPG; Clopidogrel

(Phytomenadione/phytonadione) Phytomenadione (generik)

12.1 OBAT KONTRAS

2 Etakridin Lakta (Rivanol) Larutan 0,1% Rivanol

2 Boraks Gliserin Larutan 10% GOM

16.2 HORMON KELAMIN OBAT YANG

16.3 HORMON TIROID DAN

mg + 2 mg, Colergis Syrup; Ocuson Tablet

Krim, Orabase, Injeksi IA/ID Kenacort Tablet; Flamicort

1 Alendronat Tablet 10 mg Allovel

6 Nitrogliserin Kapsul 2,5 mg, 5 mg Nitrokaf Retard 2,5 mg, Retard

3 Propranolol HCl Tablet 10 mg, 40 mg Propranolol (generik)

2 Propranolol HCl Tablet 10 mg, 40 mg Propranolol (generik)

1 Terazosin HCL Tablet 1 mg, 2 mg Hytrin

5 Telmisartan Tablet 40 mg, 80 mg Micardis

17.5 OBAT UNTUK SYOK

Injeksi 4 mg; Cortidex Injeksi 5 mg,

Trolip 300 mg; Fenofibrate

1 Beraprost Tablet 20 mcg Dorner

6 Fluprednidin-21-Asetat Krim 0,1% (10 Decoderm

11 Kloramfenikol Salep 2% Chloramfecort

4 Klotrimazol + Deksametason Krim 1% + 0,04% Baycuten N

galatoarabinan) + Sophora japonica dan

Ceradan Cream; Lactacyd Baby

6 Oralit Serbuk, 100 gram per Oralit KF Sachet; Pharolit

2 Asam Amino Infus Berbagai Aminosteril Infant 6%; Pan

silitol 60 gram, elektrolit dan vitamin

laktat 20 mek glukosa 100 gram

Natrium Klorida 0,9%= 4;1 (N4)

2 Latanoprost Tetes Mata 0,5% Glaopen MD

Nafazolin Tetes Mata 0,25 mg per Cendo Vernacel MD

Hialuronat + NaCl + Na Hidrogenfosfat

injeksi 10 Hystolan Tablet; Proterin Tablet

injeksi 0,5 Lasmalin Tablet

1 Amitriptilin HCL Tablet 25mg Amitriptilin HCL 25 mg

2 Kloralhidrat Serbuk Chloralhydrat Pulv (generik)

24.2 OBAT UNTUK MISTENIAGRAVIS