1.

SATUAN KERJA ADALAH NAMA APOTEK, KLINIK, FKTP, FKRTL, DINKES PROVINSI dan KAB/KOTA atau BKKBN
2. JUMLAH KEBUTUHAN TAHUN 2021 ADALAH PEMAKAIAN RATA-RATA PER BULAN SELAMA 2020 DIKALI 18 BULAN DALAM SA
3. RENCANA KEBUTUHAN TAHUN 2021 ADALAH RENCANA KEBUTUHAN YANG DIHITUNG BERDASARKAN METODE KONSUMSI
4. RENCANA PENGADAAN TAHUN 2021 ADALAH RENCANA OBAT DALAM SATUAN TERKECIL SEPERTI: TABLET / KAPSUL / KAPL
5. SURAT PENGANTAR DAN LAMPIRAN HARUS DI TANDATANGANI OLEH KEPALA SATUAN KERJA DAN DIBERI STEMPEL
6. MOHON UNTUK TIDAK MELAKUKAN PENAMBAHAN MAUPUN PENGURANGAN BARIS/KOLOM PADA FORMAT

RENCANA KEBUTUHAN OBAT PADA FASILITAS KESEHATAN TINGKAT PERTAMA (FKTP

UPTD TAMPAKSIRING 2
SATUAN KERJA : Dinas Kesehatan Kab. Gianyar

NO NAMA OBAT SATUAN SISA STOK PEMAKAIAN

PER 31 RATA-RATA
DESEMBER PER BULAN
2023 SELAMA 2023

(a) (b)
1 Air untuk injeksi amp 20 ml ampul/vial/botol 0 2
2 Air untuk injeksi amp 25 ml ampul/vial/botol 25 mL 0 0
3 Albendazol susp 200 mg/5 ml Botol 10
4 Albendazol tab 400 mg tablet/kapsul/kaplet 0 200
5 Alopurinol tab 100 mg Tab 3,500 1,500
6 Alopurinol tab 300 mg tablet/kapsul/kaplet 0 500
7 Aminofilin inj 24 mg/ml ampul/vial 10 ml 0 0
8 Aminofilin tab 150 mg tablet/kapsul/kaplet 0 0
9 Aminofilin Tab 200 mg tablet/kapsul/kaplet 0 0
10 Amitriptilin tab sal 25 mg tablet/kapsul/kaplet 0 100
11 Amlodipin tab 10 mg tablet/kapsul/kaplet 5,000
12 Amlodipin tab 5 mg tablet/kapsul/kaplet 4,200 10,000
13 Amoksisilin drops 100 mg/ml Botol 0 10
14 Amoksisilin sir forte 250 mg/5 ml botol 60 ml 100

15 Amoksisilin sir kering 125 mg/5 ml Botol 0 100

16 Amoksisilin tab 250 mg tablet/kapsul/kaplet 0 200

17 Amoksisilin tab 500 mg tablet/kapsul/kaplet 11,800 6,500
18 Ampisilin serb inj 1000 mg/vial ampul/vial 0 0
19 Ampisilin serb inj 250 mg/vial Vial 0 0
20 Anestetik lokal gigi kombinasi : ampul/vial 20 30
lidokain hcl 2% + epinefrin 1 : 80.000
inj 2 ml
21 Antasida, kombinasi : aluminium tablet/kapsul/kaplet 1,200 2,500
hidroksida 200 mg + magnesium
hidroksida 200 mg

22 Antasida, kombinasi : aluminium botol 60 ml 0 30

hidroksida 200 mg + magnesium
hidroksida 200 mg

23 Anti Parkinson kombinasi : Kaps 0 0

benzerasid 25 mg + levodopa 100
mg

24 Antifungi salep, kombinasi : asam pot 30 g 0 30

benzoat 6%+ asam salisilat 3%

25 Antihemoroid, kombinasi: bismut Suppositoria 0 20

subgalat 150 mg + heksaklorofen 2,5
mg + lidokain lidokain 10 mg+ seng
oksida 120 mg + sup ad 2 g

26 Artesunat serb inj 60 mg/ml ampul/vial 0 0

(i.v./i.m.)
27 Articulating paper kertas warna Kertas warna penanda oklusi 0 1
penanda oklusi
28 Asam asetat tetes telinga 2% Botol 0 0
29 Asam asetilsalisilat (asetosal) tab 80 tablet/kapsul/kaplet 0 10
mg
30 Asam askorbat (vitamin C) tab 250 Tab 0
mg
31 Asam askorbat (vitamin C) tab 50 tablet/kapsul/kaplet 3,000 2,000
mg
32 Asam folat tab 0,4 mg tablet/kapsul/kaplet 0 0
33 Asam folat tab 1 mg tablet/kapsul/kaplet 3,500 1,500
34 Asam folat tab 5 mg Tab 0 100
35 Asam mefenamat kaps 250 mg tablet/kapsul/kaplet 0 0
36 Asam mefenamat kaps 500 mg tablet/kapsul/kaplet/kaptab 4,700 2,000
37 Asam salisilat lar 0,1% Botol 0 0
38 Asam salisilat salep 10% Tube 0 0
39 Asam salisilat salep 2% Tube 0 10
40 Asam salisilat salep 5% Tube 0 0
41 Asiklovir tab 200 mg tablet/kapsul/kaplet 0 50
42 Asiklovir tab 400 mg tablet/kapsul/kaplet 2,000 200
43 Atapulgit 600 mg tablet/kapsul/kaplet 0 300
44 Atapulgit tab 630 mg tablet/kapsul/kaplet 3,000 700
45 Atapulgit tablet 650 mg tablet/kapsul/kaplet 0 300
46 Atapulgit tablet 750 mg Tab 0 300
47 Atenolol tab 100 mg tablet/kapsul/kaplet 0 0
48 Atenolol tab 50 mg tablet/kapsul/kaplet 0 0
49 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) Ampul 0 0

50 Atropin tab 0,5 mg Tab 0 0

51 Bahan tumpatan sementara lar, serb Botol 0 0

52 Bedak salisil serb 2% Dus/Sachet/Plastik 50

53 Betametason krim 0,1% tube 5 gram 0 75
54 Betametason krim 0,5 mg/g Tube 0 75
55 Betametason salep 0,1% tube 5 gram 0 50
56 Betametason tts mata 1 mg/ml botol 0 0
57 Bisakodil sup 10 mg Suppositoria 0 5
58 Bisakodil sup 5 mg Suppositoria 0 5
59 Bisakodil tab sal 5 mg tablet/kapsul/kaplet 0 0
60 Budesonid cairan ih 0,25mg/ml Botol @ 4 ml 0 0
61 Budesonid cairan ih 0,25mg/ml, respoules 0 0
respoules 2 ml
62 Budesonid cairan ih 0,5 mg/ml Botol @ 4 ml 0 0
63 Budesonid cairan ih 0,5 mg/ml, respoules 0 0
respoules 2 ml
64 Budesonid serb ih 100 mcg/dosis Botol 0 0

65 Budesonid serb ih 200 mcg/dosis 100 dosis 0 0

66 Budesonid serb ih 200 mcg/dosis 200 dosis 0 0

67 Coal tar lar 5 % Botol 0 0

68 Copper T set/buah 0 0
69 Deksametason inj 5 mg/ml (i.v./i.m.) ampul/vial 7

70 Deksametason tab 0,5 mg tablet/kapsul/kaplet 5,716 2,000

71 Diazepam enema 10 mg/2,5 ml tube @ 2,5 mL 0 5
72 Diazepam enema 5 mg/2,5 ml tube @ 2,5 mL 5 5
73 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial 0 3
74 Diazepam tab 2 mg tablet/kapsul/kaplet 0 0
75 Diazepam tab 5 mg tablet/kapsul/kaplet 0 600
76 Dietilkarbamazin tab 100 mg tablet/kapsul/kaplet 0 0
77 Difenhidramin inj 10 mg/ml ampul/vial 60 5
(i.v./i.m.)
78 Digoksin tab 0,25 mg tablet/kapsul/kaplet 0 0
79 Diltiazem hcl tab 30 mg tablet/kapsul/kaplet 0 0
80 Diltiazem kaps SR 100 mg Kapsul lepas lambat 0 0
81 Diltiazem kaps SR 200 mg Kapsul lepas lambat 0 0
82 Diltiazem tab 30 mg Tab 0 0
83 Dimenhidrinat tab 50 mg tablet/kapsul/kaplet 0 0
84 Doksisiklin kaps 100 mg tablet/kapsul/kaplet 0 0
 85 Domperidon susp 5 mg/5 ml botol @60 ml 0 20
86 Domperidon tab 10 mg tablet/kapsul/kaplet 0 50
87 Epinefrin (adrenalin) inj 0,1% ampul/vial 15 5
(i.v./s.k./i.m.)
88 Epinefrin (adrenalin) inj 1 mg/ml Ampul 0 5

89 Ergotamin tab 1 mg Tab 0 0

90 Eritromisin kaps 250 mg tablet/kapsul/kaplet 0 0
91 Eritromisin sir 200 mg/5 ml Botol @ 60 ml 0 0
92 Eritromisin tab 500 mg tablet/kapsul/kaplet 0 0
93 Estrogen terkonjugasi tab sal 0,625 tablet salut gula/kaplet salut gula 0 0
mg
94 Etanol 70% cairan 70% Botol 12 7
95 Etil klorida semprot 100 ml Botol 0 1
96 Etonogestrel implan 68 mg Set 0 0
97 Eugenol Botol 0 0
98 Fenitoin Na inj 50 mg/ml ampul @ 2 ml 0 0
99 Fenitoin Na kaps 100 mg Kaps 0 0
100 Fenitoin Na kaps 30 mg Kaps 0 0
101 Fenobarbital tab 100 mg Tab 0 0
102 Fenobarbital tab 30 mg tablet/kapsul/kaplet 1,500 1,000
103 Fenoksimetil penisilin (penisilin V) Tab 0 0
tab 250 mg
104 Fenoksimetil penisilin (penisilin V) Tab 0 0
tab 500 mg
105 Ferro fumarat kaps lunak 300 mg Kaps lunak 0 2,000

106 Ferro sulfat sir. 150 mg/5 ml Botol 0 0

107 Ferro sulfat tab salut 300 mg Tab sal 0 0
108 Fitomenadion (vitamin K 1) inj 2 ampul/vial 0 20
mg/ml (i.m.)
109 Fitomenadion (vitamin K 1) tab sal Tab sal 0 0
10 mg
110 Fitomenadion (vitamin K1) inj 10 tablet salut gula/kaplet salut gula 0 0
mg/ml (i.m)
111 Fluoksetin kaps 10 mg tablet/kapsul/kaplet 0 0
112 Fluor kapl 1 mg Kaplet 0 0
113 Fluor sediaan topikal Tube 0 0
114 Fluoresein tts mata 2,5 mg/ml Botol 0 0
115 Formokresol Botol 0 0
116 Framisetin Sulfat Tulle 1% Patch 0 0
117 Furosemid inj 10 mg/ml (i.v./i.m.) ampul/vial 0 0

118 Furosemid tab 40 mg tablet/kapsul/kaplet 0 10

119 Galactose microparticle 200-400 mg Vial 0 0
micropart/ml
120 Garam oralit kombinasi : natrium sachet 200 200
klorida 0,52 g + kalium klorida 0,30 g
+ trinatrium sitrat 0,58 g + glukosa
anhidrat 2,7 g

121 Gentamisin salep mata 0,3% Tube 0 20

122 Gentamisin tts mata 0,3% Botol 0 25
123 Glass ionomer ART (Atraumatic Sachet 0 0
Restorative Treatment) cocoa butter
5g

124 Glass ionomer ART (Atraumatic Botol 0 0

Restorative Treatment) lar
125 Glass ionomer ART (Atraumatic Vial 0 0
Restorative Treatment) serb
126 Glibenklamid tab 2,5 mg tablet/kapsul/kaplet 0 0
127 Glibenklamid tab 5 mg tablet/kapsul/kaplet 3,000 3,000
128 Glikuidon tab 30 mg tablet/kapsul/kaplet 0 0
129 Glimepirid tab 1 mg tablet/kapsul/kaplet 0 1,000
130 Glimepirid tab 2 mg tablet/kapsul/kaplet 300 1,000
131 Glipizid tab 5 mg tablet/kapsul/kaplet 0 0
132 Gliseril trinitrat tab 0,5 mg tablet/kapsul/kaplet 0 0
133 Gliserin tts 100 mg/ml Botol 0 20
134 Glukosa Larutan Infus 10% steril 100 Botol 0 0
ml
135 Glukosa Larutan Infus 10% steril 250 Botol 0 0
ml
136 Glukosa Larutan Infus 10% steril 500 Botol 0 1
ml
137 Glukosa Larutan Infus 40% Ampul @25 ml 0 0
138 Glukosa Larutan Infus 5% steril 100 Botol 0 0
ml
139 Glukosa Larutan Infus 5% steril 250 Botol 0 0
ml
140 Glukosa Larutan Infus 5% steril 500 Botol 0 0
ml
141 Griseofulvin (micronized) tab 125 tablet/kapsul/kaplet 0 0
mg
142 Griseofulvin (micronized) tab scored tablet/kapsul/kaplet 0 0
250 mg
143 Gutta percha dan paper points 15 - Roll 0 0
40 mm
144 Gutta percha dan paper points 45 - Roll 0 0
80 mm
145 Haloperidol inj 5 mg/ml (i.m.) Vial 0 0
146 Haloperidol tab 0,5 mg tablet/kapsul/kaplet 0 0
147 Haloperidol tab 1,5 mg tablet/kapsul/kaplet 0 0
148 Haloperidol tab 2 mg tablet/kapsul/kaplet 0 0
149 Haloperidol tab 5 mg tablet/kapsul/kaplet 700 700
150 Haloperidol tts 2 mg/ml botol 0 0
151 Hepatitis B imunoglobulin (human) Ampul 0 0
inj 150 IU/1,5 ml
152 Hidrogen peroksida cairan 3% Botol 0 2
153 Hidrogen peroksida lar. Konsentrat Botol 0 0
3%
154 Hidroklorotiazid tab 25 mg tablet/kapsul/kaplet 0 0
155 Hidrokortison krim 2,5% tube @ 5 g 50 75
156 Hidrokortison serb inj 100 mg Vial 0 0
157 Hiosina butilbromida tab 10 mg tablet/kapsul/kaplet 0 0
158 Human tetanus imunoglobulin inj Ampul 20 50
250 UI (i.m.)
159 Human tetanus imunoglobulin inj Ampul 0 0
500 UI (i.m.)
160 Ibuprofen sir 100 mg/5 ml botol @ 60 ml 0 0
161 Ibuprofen sir 200 mg/5 ml botol @ 60 ml 0 0
162 Ibuprofen tab 200 mg tablet/kapsul/kaplet 0 0
163 Ibuprofen tab 400 mg tablet/kapsul/kaplet 800
164 Ipratropium bromida aerosol 20 Botol 0 0
mcg/semprot
165 Ipratropium bromida cairan ih Botol 0 20
0,025%
166 Ipratropium bromida ih 20mcg/puff Botol 0 0

167 Isoniazid tab 100 mg Tab 0 0

168 Isoniazid tab 300 mg Tab 0 0
169 Isosorbid dinitrat tab 5 mg tablet/kapsul/kaplet 0 0
170 IUD Cu T 380 A Set 0 0
171 IUD Levonorgestrel Set 0 0
172 Kalamin Tube 0 50
173 Kalsium glukonat inj 100 mg/ml ampul/vial 0 0
174 Kalsium hidroksida bubuk, pasta Tube 0 0

175 Kalsium karbonat tab 500 mg tablet/kapsul/kaplet 0 0

176 Kalsium laktat (kalk) tab 500 mg tablet/kapsul/kaplet 2,420 700
177 Kaptopril tab 12,5 mg tablet/kaplet 1,940 0
178 Kaptopril tab 25 mg tablet/kaplet 5,250 4,000
179 Kaptopril tab 50 mg tablet/kaplet 0 0
180 Karbamazepin sir 100 mg/5 ml Botol 0 0
181 Karbamazepin tab 100 mg Tab 0 0
182 Karbamazepin Tab 200 mg Tablet 800 600
183 Karbo adsorben tab 0,5 g Tab 0 0
184 Karbogliserin tts telinga 10 % Botol 0 50
185 Ketokonazol tab 200 mg tablet/kapsul/kaplet 50
186 Klindamisin kaps 150 mg Kaps 0 0
187 Klindamisin kaps 300 mg tablet/kapsul/kaplet 0 0
188 Klofazimin, micronized kaps 50 mg Kapsul 0 0

189 Klofazimin, micronizedkaps 100 mg kapsul 0 0

190 Klonidin tab 0,15 mg tablet/kapsul/kaplet 0 0

191 Kloramfenikol kaps 250 mg tablet/kapsul/kaplet 0 0
192 Kloramfenikol salep kulit 2% tube 15g 0 30
193 Kloramfenikol salep mata 1% tube @ 5 gram 0 15
194 Kloramfenikol susp 125 mg/5 ml botol 60 ml 0 5
195 Kloramfenikol tetes telinga 3% Botol 0 15
196 Kloramfenikol tts mata 0,5% botol 0 10
197 Kloramfenikol tts mata 1% Botol 0 0
198 Klorfeniramin tab 4 mg tablet/kapsul/kaplet 3,000 2,000
199 Klorfenol kamfer mentol (CHKM) Botol 0 0

200 Klorheksidin lar 0,2% Botol 0 0

201 Klorheksidin lar 15% Botol 0 0
202 Klorpromazin inj 25 mg/ml (i.m.) ampul/vial 0 0

203 Klorpromazin inj 5 mg/ml (i.m.) ampul/vial 0 0

204 Klorpromazin tab sal 100 mg tablet salut selaput/kaplet salut sela 0 0
205 Klorpromazin tab sal 25 mg Tab sal 0 0
206 Klortalidon tab 50 mg Tab 0 0
207 Klozapin tab 100 mg tablet 0 0
208 Klozapin tab 25 mg tablet 0 0
209 Kodein tab 10 mg tablet/kapsul/kaplet 0 0
210 Kombinasi (DHP) : dihidroartemisin tablet salut selaput/kaplet salut sela 0 0
40 mg + Piperakuin 320 mg tab sal
selaput

211 Kombinasi : artemether 20 mg + tablet/kapsul/kaplet 0 0

lumefantrin 120 mg
212 Kombinasi : artesunat tab 50 mg + Tab 0 0
amodiakuin tab 200
213 Kombinasi : Desogestrel 150 mcg Tab 0 0
Etinilestradiol 30 mcg
214 Kombinasi : ergotamin 1 mg+ kafein tablet/kapsul/kaplet 0 0
50 mg
215 Kombinasi : Ferro fumarat 60 mg + tablet salut gula 0 0
asam folat 0,4 mg tab salut
216 Kombinasi : levonorgestrel 150 mcg tab salut gula 0 0
+ etinilestradiol 30 mcg
217 Kombinasi : Tenofovir 300 mg + Tab 0 0
Emtrisitabin 200 mg
218 Kombinasi : Tenofovir 300 mg + Tab 0 0
Lamivudin 300 mg + Efavirenz 600
mg

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

salbutamol 2,5 mg nebules
220 Kombinasi: kaolin 550 mg + pektin Tab 0 0
20 mg
221 Komposit resin Set 0 0
222 Kotrimoksazol (dewasa) kombinasi : tab/kaptab 670 200
sulfametoksazol 400 mg+
trimetoprim 80 mg

223 Kotrimoksazol (dewasa) kombinasi : tab/kaptab 0 0

sulfametoksazol 800 mg+
trimetoprim 160 mg

224 Kotrimoksazol kombinasi tiap 5 ml botol 60 mL 0 5

suspensi : sulfametoksazol 200 mg +
trimetoprim 40 mg

225 Kuinin inj 25% (i.v.) Vial 0 0

226 Kuinin tab 200 mg tablet/kapsul/kaplet 0 0
227 Laktulosa sir 3,335 g/5 ml botol @ 60 mL 0 5
228 Larutan mengandung Elektrolit Botol 0 0
(Kalium Klorida)
229 Larutan mengandung Elektrolit (KCl Botol 0 1
0,15%, NaCL 0,9%) (KN1)
230 Larutan mengandung Elektrolit (KCl Botol 0 0
0,3%,NaCl 0,9%) (KN2)
231 Larutan mengandung Elektrolit (Na Softbag @ 500 ml 0 0
130 mEq, K 4 mEq, Cl 109 mEq, Ca 3
mEq, Asetat 28 mEq) Ringer Asetat

232 Larutan mengandung Elektrolit (Na Botol plastik @ 500 ml 0 0

130 mEq, K 4 mEq, Cl 109 mEq, Ca 3
mEq, Asetat 28 mEq) Ringer Asetat

233 Larutan mengandung Elektrolit Botol 0 0

(NaCl 1.125 gr, Dekstrosa 18.75 gr)
(KA EN 1B)
234 Larutan mengandung Elektrolit Botol 0 0
(Sodium Lactate sol (50%) 113 gr/L,
Potassium Chloride 0.3 gr/L, Calcium
Chloride 0.2 gr/L, elektrolit)

235 Larutan mengandung Elektrolit (Tiap Botol 0 0

1000 ml mengandung electrolit:
Sodium 145 mmol/l, Potassium 4.0
mmol/l, Calcium 2.5 mmol/l,
Magnesium 1.0 mmol/l, Chloride
118 mmol/l, Acetate 24 mmol/l,
Malate 5.0 mmol/l)

236 Larutan mengandung Karbohidrat Botol 0 0

(Fructose 120 g, glucose 66 g, Xylitol
60 g/ L)

237 Larutan mengandung Karbohidrat Botol 0 0

(Fructose 200 g, glucose 110 g,
Xylitol 100 g/ L)

238 Larutan mengandung Karbohidrat Botol 0 0

(Fructose 60 g, glucose 33 g, Xylitol
30 g/ L)

239 Larutan mengandung Karbohidrat Botol 0 0

(Maltose 10%)
240 Larutan mengandung Karbohidrat + Botol 0 0
Elektrolit (25.00g maltose, 3.00 g
sodium chloride, 0.15 g potassium
chloride, 0.10 g calcium chloride
dihydrate dan 1.55 g sodium lactate)

241 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (Acetate, Na, K, Cl, Ca, Mg,
Sorbitol 50 gr/L)

242 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (Dextrose 5%, NaCL 0,45%,
KCl) (HSD)

243 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (Fructose 120 g, glucose 66
g, Xylitol 60 g/ L + elektrolit)
244 Larutan mengandung Karbohidrat + Botol 0 0
Elektrolit (Glukosa 25 g, NaCl 2,0 g,
KCl 1,3 g, Natrium Laktat 3,1 g, air
untuk injeksi ad 1000 ml)

245 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (Glukosa 55 g ; Natrium
Chloride 9 g, air untuk injeksi ad
1000 ml) (D5-NS)

246 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (Glukosa: 25,0 g; NaCl: 4,5
g)

247 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (Glukosa: 55.0 g; NaCl:
2.25 g) (D5-1/4NS)

248 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (Glukosa: 55.0 g; NaCl: 4.5
g) (D5-1/2NS)

249 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (Larutan nutrisi kombinasi
infus per L: Na. 100mEQ, K 18mEQ,
Ca. 4mEQ, Mg 6mEQ, Cl 90mEQ,
Asetat 38mEQ, Sorbitol 50g)

250 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (Larutan Ringer & Glukosa
5%)

251 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (NaCl 1.75 g, KCL 1.5g,
Glukosa 100 gr)

252 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (NaCl 1.75 g, KCL 1.5g, Na
Lactate 2.24 g, Glukosa 100 gr)

253 Larutan mengandung Karbohidrat + Botol 0 0

Elektrolit (Nacl 1.75 gr, KCl 1.5 gr, Na
Lactat 2.24 gr, Dekstrosa 27 gr) (KA
EN 3B)
254 Larutan mengandung Karbohidrat + Botol 0 0
Elektrolit (Nacl 2.34 gr, Na Laktat
2.24 gr, KCL 0.75 gr Dekstrosa 27 gr)
(KA EN 3A)

255 Levonorgestrel implan 2 rods, 75 mg pack/ sachet/ set 0 0

(3-4 tahun)
256 Lidokain gel 2% syringe/syringe plastik 0 2
257 Lidokain inj 2% (infiltr/p.v.) ampul/vial 0 40
258 Lidokain spray oral 10% botol 0 1
259 Linestrenol tab 0,5 mg tablet/kapsul/kaplet 0 0
260 Loperamid tab 2 mg Tab 0 0
261 Loratadin tab 10 mg tablet/kapsul/kaplet 0 50
262 Lorazepam tab 0,5 mg tablet/kapsul/kaplet 0 0
263 Lorazepam tab 1 mg tablet/kapsul/kaplet 0 0
264 Lorazepam tab sal 2 mg Tab sal 0 0
265 Lugol Botol 0 0
266 Magnesium sulfat inj 20% ampul/vial 0 2
267 Magnesium sulfat inj 20% ampul/vial @25 ml 0 2
268 Magnesium sulfat inj 40% ampul/vial @25 ml 0 2
269 Magnesium sulfat inj 40% ampul/vial 0 0
270 Magnesium sulfat serb, ktg 30 g Sachet 0 0
271 Mebendazol sir 100 mg/5 ml Botol 0 0
272 Mebendazol tab 100 mg Tan 0 0
273 Mebendazol tab 500 mg tablet/kapsul/kaplet 0 0
274 Medroksi progesteron asetat inj 150 ampul/vial 0 0
mg/ml
275 Medroksi Progesteron Asetat Inj 50 ampul/vial 0 0
mg/ml
276 Metenamin mandelat (heksamin Tab salut 0 0
mandelat) tab salut enterik 500 mg

277 Metformin tab 500 mg tablet/kapsul/kaplet 8,000 6,000

278 Metformin tab 850 mg tablet/kapsul/kaplet 0 0
279 Metilergometrin inj 0,2 mg/ml ampul/vial 0 3
280 Metilergometrin tab salut 0,125 mg tablet/kaplet salut selaput 0 0

281 Metilprednisolon tab 4 mg tablet/kapsul/kaplet 2,000 3,000

282 Metoklopramid inj 5 mg/ml ampul/vial 0 0
283 Metoklopramid tab 10 mg tablet/kapsul/kaplet 0 0
284 Metoklopramid tab 5 mg tablet/kapsul/kaplet 0 0
285 Metronidazol lar inf 5 mg/ml botol 0 0
286 Metronidazol susp 125 mg/5 ml Botol @ 60 ml 0 0
287 Metronidazol susp 125 mg/5 ml Botol @ 100 ml 0 0
288 Metronidazol tab 250 mg tablet/kapsul/kaplet 0 0
289 Metronidazol tab 500 mg tablet/kapsul/kaplet 200 50
290 Mikonazol krim 2% tube 0 50
291 Mikonazol serb 2% botol / sachet 0 30
292 Mineral Mix (Bismuth Subcitrate Sachet 0 0
Tripotasium, Copper sulfate,
Magnesium Chloride Anhydrous,
Potassium Chloride, Zinc Acetate)

293 N-asetil sistein kaps 200 mg tablet/kapsul/kaplet 500 2,000

294 NaCl 0,9% Larutan Botol plastik/botol plastik pi 60 20
295 NaCl 0,9% Larutan Botol 0 0
296 NaCl 0,9% Larutan ampul/botol plastik/botol plas 0 0
297 Natrium diklofenak tab 25 mg tablet salut enterik/kaplet salut ente 0 0
298 Natrium diklofenak tab 50 mg tablet salut enterik/kaplet salut ente 1,000 2,000
299 Natrium Diklofenak Tetes Mata 1 botol 5 mL 0 0
mg/ml
300 Natrium hipoklorit cairan konsentrat Botol 0 0
5%
301 Natrium tiosulfat inj 25% (i.v.) Ampul 0 0
302 Nifedipin kaps 10 mg tablet/kapsul/kaplet 0 10
303 Nikotinamid tab 100 mg Tab 0 0
304 Nikotinamid tab 5 mg Tab 0 0
305 Nistatin susp 100.000 UI/ml botol/vial 0 0
306 Nistatin tab salut 500.000 UI tablet salut gula/kaplet salut gula 0 0
307 Nistatin tab vaginal 100.000 UI tablet/kaplet 0 30
308 Nitrofurantoin tab 50 mg Tab 0 0
309 Norepinefrin inj 1 mg/ml ampul/vial 0 0
310 Obat Anti Tuberculosis FDC Kategori paket 0 0
Anak
311 Obat Anti Tuberculosis FDC Kategori paket 0 0
I
312 Obat Anti Tuberculosis FDC Kategori paket 0 1
II
313 Obat Anti Tuberculosis FDC Kategori paket 0 0
Sisipan
314 Obat Anti Tuberculosis Kombipak Paket 0 0
Anak
315 Obat Anti Tuberculosis Kombipak paket 0 0
Dewasa
316 Oksigen ih, gas dlm tabung Botol 0 3
317 Oksimetazolin tts hidung 0,025% botol @ 10 mL 0 3

318 Oksimetazolin tts hidung 0,050% botol @ 10 mL 0 10

319 Oksitetrasiklin 1% Salep Mata tube 0 20

320 Oksitosin inj 10 UI/ml ampul/vial 0 10
321 Olopatadin tts mata 0,1% Botol 0 0
322 Omeprazol inj 40 mg/10 ml ampul/vial 0 0
323 Omeprazol kaps 20 mg tablet/kapsul/kaplet 0 1,000
324 Paraformaldehid tab 1 g Tab 0 0
325 Parasetamol sir 120 mg/5 ml botol @ 60 mL 0 150
326 Parasetamol tab 500 mg tablet/kapsul/kaplet 2,000 10,000
327 Parasetamol tts 60 mg/0,6 ml botol @ 15 mL 60 100
328 Pasta devitalisasi (non arsen) Tube 0 0
329 Pasta pengisi saluran akar (pasta) Tube 0 0

330 Perak nitrat lar 20% Botol 0 0

331 Perak sulfadiazin krim 1% Tube 0 4
332 Permetrin krim 5 % Tube 0 0
333 Pirantel pamoat susp 125 mg/5 ml Botol 0 0

334 Pirantel pamoat tab 500 mg Tab 0 0

335 Pirantel pamoat tab scored 125 mg tablet/kapsul/kaplet 0 0

336 Pirantel pamoat tab scored 250 mg Tab 0 0

337 Piridoksin (vitamin B6) inj 100 Ampul 0 0

mg/ml
338 Piridoksin (vitamin B6) tab 10 mg tab/kap/kapl 0 0

339 Piridoksin (vitamin B6) tab 25 mg tablet/kapsul/kaplet 600 50

340 Povidon iodin lar 100 mg/ml botol @ 1.000 mL 0 0

341 Povidon iodin lar 100 mg/ml botol 30 mL 0 0
342 Povidon iodin lar 100 mg/ml botol @ 60 mL 0 0
343 Povidon iodin lar 100 mg/ml Botol 300 ml 30 5
344 Prednison tab 5 mg tablet/kapsul/kaplet 0 0
345 Primakuin tab 15 mg Tab 0 0
346 Probenesid tab 500 mg tablet/kapsul/kaplet 0 0
347 Prokain benzilpenisilin serb inj 3 juta ampul/vial 0 0
UI/vial (i.m.)
348 Propiltiourasil tab 100 mg tablet/kapsul/kaplet 0 0
349 Propranolol tab 10 mg tablet/kapsul/kaplet 0 0
350 Ranitidin tab 150 mg tablet/kapsul/kaplet 500
351 Retinol (vitamin A) kaps lunak kaps lunak 0 10
100.000 UI
352 Retinol (vitamin A) kaps lunak kaps lunak 0 10
200.000 UI
353 Rifampisin kaps 300 mg tablet/kapsul/kaplet 0 0
354 Ringer Laktat Larutan Botol 0 10
355 Risperidon tab sal 1 mg tablet/kapsul/kaplet 0 0
356 Risperidon tab sal 2 mg tablet/kapsul/kaplet 0 0
357 Salbutamol cairan ih 0,1% ampul/vial/botol 0 0
358 Salbutamol lar ih 0,5 % Botol 0 20
359 Salbutamol sir 2 mg/5 ml Botol 0 0
360 Salbutamol tab 2 mg tablet/kapsul/kaplet 0 0
361 Salbutamol tab 4 mg tablet/kapsul/kaplet 2,000 700
362 Salep 2-4, kombinasi : asam salisilat pot 30 gram 0 30
2 %+ belerang endap 4 %

363 Salep 2-4, kombinasi : asam salisilat pot 15 gram 0 10

2 %+ belerang endap 4 %

364 Serum anti bisa ular : A.B.U. I Vial 0 0

(khusus ular dari luar Papua) inj
(i.m./i.v.)

365 Serum anti bisa ular :A.B.U.II Vial 0 0

(khusus ular dari Papua) inj (i.m./i.v.)

366 Serum antidifteri (A.D.S) inj Vial 0 0

(i.m./i.v.) Inj i.m 10.000 UI/
367 Serum antirabies inj 100 UI/ml Vial 0 0
368 Serum antirabies inj 200 UI/ml Vial 0 0
369 Serum antitetanus (A.T.S) (i.m.) Inj Vial 0 0
10.000 UI/vial (i.m /i.v.)
370 Serum antitetanus (A.T.S) inj 1500 Ampul 0 0
UI/amp (i.m.)
371 Serum antitetanus (A.T.S) inj 20.000 Vial 0 0
UI/vial (i.m /i.v.)
372 Setirizin sir 5 mg/5 ml. botol @ 60 mL 150
373 Sianokobalamin (vitamin B12) inj ampul/vial 0 0
500 mcg/ml
374 Sianokobalamin (vitamin B12) tab tablet/kapsul/kaplet 0 500
50 mcg
375 Simvastatin tab sal 10 mg tablet/kapsul/kaplet/tablet salut sel 0 200
376 Simvastatin tab sal 20 mg tablet/kapsul/kaplet/tablet salut selaput/kaplet salu 400
377 Simvastatin tab sal selaput 40 mg Tab sal 0 0

378 Siprofloksasin tab scored 500 mg tablet salut selaput/kaplet salut sela 0 200

379 Siprofloksasin tetes mata 3 mg/ml Catchcover, botol 0,6 ml 0 0

380 Spironolakton tab 25 mg tablet/kapsul/kaplet 0 0

381 Stannous pyrophosphate 27,6 mg Vial 0 0
sodium pyrophosphate/vial
382 Streptomisin serb inj 1.000 mg/vial ampul/vial 0 0

383 Surgical ginggival pack Tube 0 0

384 Tenofovir tab 300 mg tablet salut selaput/kaplet salut sela 0 0
385 Tetanus toxoid inj Ampul 0 0
386 Tetrakain tts mata 0,5% Botol 0 0
387 Tetrasiklin kaps 250 mg tablet/kapsul/kaplet 0 0
388 Tetrasiklin kaps 500 mg tablet/kapsul/kaplet 0 0
389 Tetrasiklin Salep Mata 1% Tube 0 0
390 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/kaplet 8,000
391 Timolol tts mata 0,25% botol @ 5 mL 0 0
392 Timolol tts mata 0,5% botol @ 5 mL 0 0
393 Triheksifenidil tab 2 mg tablet/kapsul/kaplet 1,000 600
394 Urea krim 10 % pot 0 0
395 Vaksin BCG inj (i.k) Vial 0 0
396 Vaksin bivalen OPV (b-OPV) drops Vial 0 0
10 dosis
397 Vaksin Hepatitis Rekombinan Inj Vial 0 0
Prefilled Injection Device (Uniject)
0,5 ml (i.m)

398 Vaksin Influenza Vial 0 0

399 Vaksin Japanese Enchepalitis (J.E) Vial 0 0

400 Vaksin jerap difteri tetanus (DT) Vial 0 0

401 Vaksin jerap difteri tetanus (Td) Vial 0 0
402 Vaksin kombinasi DPT-HB-Hib Vial 0 0
403 Vaksin measless rubella (MR) Inj 0,5 Vial 0 0
mL (s.k)
404 Vaksin Meningitis Meningokokus Vial 0 0

405 Vaksin polio IPV inj 0,5 ml Vial 0 0

406 Vaksin rabies, untuk manusia serb Vial 0 0
inj (s.k./i.k) + booster
407 Vaksin rabies, untuk manusia serb Vial 0 0
Inj 2,5 IU
408 Vaksin Yellow Fever Vial 0 0
409 Valproat sir 250 mg/5 ml botol @ 120 ml 0 0
410 Valproat tab sal 250 mg tablet salut enterik/ kaplet salut ente 0 0
411 Valproat tab sal 500 mg Tab sal 0 0
412 Vitamin B kompleks tablet 2,000 10,000
413 Zinc drops 10 mg/ml Botol 0 10
414 Zinc serb 10 mg Sachet 0 0
415 Zinc sir 10 mg/ml Botol 0 0
416 Zinc sir 20 mg/5 ml botol 0 0
417 Zinc tab disp 20 mg tablet dispersible 0 500
IKALI 18 BULAN DALAM SATUAN TERKECIL SEPERTI : TABLET / KAPSUL / KAPLET / BOTOL / AMPUL / VIAL / TUBE / SACCHET / PUFF
KAN METODE KONSUMSI DIKURANGI DENGAN SISA STOK PER 31 DESEMBER 2020
: TABLET / KAPSUL / KAPLET / BOTOL / AMPUL / VIAL / TUBE / SACCHET / PUFF YANG AKAN DIADAKAN TAHUN 2021 BERDASARKAN PERKI
N DIBERI STEMPEL
DA FORMAT

T PERTAMA (FKTP) TAHUN 2024

JUMLAH RENCANA RENCANA RENCANA REALISASI KETERANGAN

KEBUTUHAN KEBUTUHAN PENGADAAN PENGADAAN PENGADAAN
TAHUN 2023 TAHUN 2023 TAHUN 2023 TAHUN 2022 TAHUN 2021

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

36 36 0 0 0
0 0 0 0 0
180 180 0 0 0
3,600 3,600 0 0 0
27,000 23,500 0 0 0
9,000 9,000 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
1,800 1,800 0 0 0
90,000 90,000 0 0 0
180,000 175,800 0 0 0
180 180 0 0 0
1,800 1,800 0 0 0

1,800 1,800 0 0 0

3,600 3,600 0 0 0
117,000 105,200 0 0 0
0 0 0 0 0
0 0 0 0 0
540 520 0 0 0
45,000 43,800 0 0 0

540 540 0 0 0

0 0 0 0 0

540 540 0 0 0

360 360 0 0 0

0 0 0 0 0

18 18 0 0 0

0 0 0 0 0
180 180 0 0 0

0 0 0 0 0

36,000 33,000 0 0 0

0 0 0 0 0
27,000 23,500 0 0 0
1,800 1,800 0 0 0
0 0 0 0 0
36,000 31,300 0 0 0
0 0 0 0 0
0 0 0 0 0
180 180 0 0 0
0 0 0 0 0
900 900 0 0 0
3,600 1,600 0 0 0
5,400 5,400 0 0 0
12,600 9,600 0 0 0
5,400 5,400 0 0 0
5,400 5,400 0 0 0
0 0 0 0 0
0 0 0 0 0
 0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

900 900 0 0 0
1,350 1,350 0 0 0
1,350 1,350 0 0 0
900 900 0 0 0
0 0 0 0 0
90 90 0 0 0
90 90 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
126 126 0 0 0

36,000 30,284 0 0 0
90 90 0 0 0
90 85 0 0 0
54 54 0 0 0
0 0 0 0 0
10,800 10,800 0 0 0
0 0 0 0 0
90 30 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
 360 360 0 0 0
900 900 0 0 0
90 75 0 0 0

90 90 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

126 114 0 0 0
18 18 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
18,000 16,500 0 0 0
0 0 0 0 0

0 0 0 0 0

36,000 36,000 0 0 0

0 0 0 0 0
0 0 0 0 0
360 360 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

180 180 0 0 0
 0 0 0 0 0

3,600 3,400 0 0 0

360 360 0 0 0
450 450 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
54,000 51,000 0 0 0
0 0 0 0 0
18,000 18,000 0 0 0
18,000 17,700 0 0 0
0 0 0 0 0
0 0 0 0 0
360 360 0 0 0
0 0 0 0 0

0 0 0 0 0

18 18 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
 0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
12,600 11,900 0 0 0
0 0 0 0 0
0 0 0 0 0

36 36 0 0 0
0 0 0 0 0

0 0 0 0 0
1,350 1,300 0 0 0
0 0 0 0 0
0 0 0 0 0
900 880 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
14,400 14,400 0 0 0
0 0 0 0 0

360 360 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
900 900 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0
12,600 10,180 0 0 0
0 -1,940 0 0 0
72,000 66,750 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
10,800 10,000 0 0 0
 0 0 0 0 0
900 900 0 0 0
900 900 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
540 540 0 0 0
270 270 0 0 0
90 90 0 0 0
270 270 0 0 0
180 180 0 0 0
0 0 0 0 0
36,000 33,000 0 0 0
0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
 0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
3,600 2,930 0 0 0

0 0 0 0 0

90 90 0 0 0

0 0 0 0 0
0 0 0 0 0
90 90 0 0 0
0 0 0 0 0

18 18 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
 0 0 0 0 0

0 0 0 0 0

36 36 0 0 0
720 720 0 0 0
18 18 0 0 0
0 0 0 0 0
0 0 0 0 0
900 900 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
36 36 0 0 0
36 36 0 0 0
36 36 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

108,000 100,000 0 0 0
0 0 0 0 0
54 54 0 0 0
0 0 0 0 0

54,000 52,000 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
 900 700 0 0 0
900 900 0 0 0
540 540 0 0 0
0 0 0 0 0

36,000 35,500 0 0 0
360 300 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
36,000 35,000 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
180 180 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
540 540 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

18 18 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

54 54 0 0 0
54 54 0 0 0

180 180 0 0 0

360 360 0 0 0
 180 180 0 0 0
0 0 0 0 0
0 0 0 0 0
18,000 18,000 0 0 0
0 0 0 0 0
2,700 2,700 0 0 0
180,000 178,000 0 0 0
1,800 1,740 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0
72 72 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

900 300 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
90 60 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
9,000 9,000 0 0 0
180 180 0 0 0

180 180 0 0 0

0 0 0 0 0
180 180 0 0 0
 0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
360 360 0 0 0
0 0 0 0 0
0 0 0 0 0
12,600 10,600 0 0 0
540 540 0 0 0

180 180 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

2,700 2,700 0 0 0
0 0 0 0 0

9,000 9,000 0 0 0

3,600 3,600 0 0 0
7,200 7,200 0 0 0
0 0 0 0 0

3,600 3,600 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
 0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
144,000 144,000 0 0 0
0 0 0 0 0
0 0 0 0 0
10,800 9,800 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
180,000 178,000 0 0 0
180 180 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
9,000 9,000 0 0 0
/ SACCHET / PUFF

2021 BERDASARKAN PERKIRAAN ANGGARAN YANG DIPEROLEH TAHUN 2021

 KEBUTUHAN BMHP TAHUN 2023

NO NAMA OBAT SATUAN SISA STOK PER PEMAKAIAN JUMLAH

31 DESEMBER RATA-RATA KEBUTUHAN
2021 PER BULAN TAHUN 2023
SELAMA 2021

(a) (b) (c) = (b) x 18

BMHP
0 10 180
1 Alkohol botol
0 10 180
2 Cairan desinfektan ruangan botol
30 5 90
3 Povidone Iodine 300 ml botol
0 20 360
4 Cairan desinfektan tangan botol
0 3 54
5 Blood Lancet box
12 10 180
6 Sabun tangan atau Anti septik Botol
0 10 180
7 Desinfektan Botol
0 10 180
8 Alkohol swab/kapas alkohol dus
0 30 540
9 Sarung tangan Steril, size 7.0 piece
0 0 0
10 Sarung tangan steril size 7.5 piece
0 5 90
11 Kantong urine piece
11 50 900
12 Masker dus
0 5 90
13 Kateter folley Dewasa piece
0 40 720
14 Sarung tangan non steril box
50 10 180
15 Infuset dewasa piece
30 6 108
16 Plester non woven roll
500 100 1,800
17 Disposable Syringe 3 cc dus
0 10 180
18 Disposable Syringe 5 cc DUS
 400 100 1,800
19 Kasa Steril 40 x 40cm pack
600 200 3,600
20 Kasa non steril 4m x 10cm piece
0 100 1,800
21 Kasa non steril 4m x 5cm roll
0 100 1,800
22 Kasa non steril 2m x 80cm pack
0 10 180
23 Kasa Steril 16 x 16 cm pack
0 5 90
24 Infuset anak piece
0 10 180
25 Infuset darah piece
Infuset dengan wing needle untuk anak 0 10 180
26 dan bayi no 25 Blister
Infuset dengan wing needle untuk anak 0 0 0
27 dan bayi no 23 Blister
0 20 360
28 Kateter intravena 20 G/Abocat piece
0 20 360
29 Kateter intravena 22 G/Abocat piece
20 360
30 Benang Chromic Catgut Sachet
0 40 720
31 Benang silk Sachet
10 180
32 Kasa non steril 36m x 80cm roll
0 10 180
33 Kapas Pembalut Hidrofil DRC 250gr roll
0 2 36
34 Pembalut Elastis 10 cm x 4,55 m roll
0 2 36
35 Pembalut Elastis 7,5 cm x 4,55 m roll
0 20 360
36 Sofratul piece
0 3 54
37 Plester Merah roll

Jika ada tambahan tulis dibawahnya lagi

RENCANA RENCANA RENCANA REALISASI HARGA SATUAN JUMLAH HARGA
KEBUTUHAN PENGADAAN PENGADAA PENGADAAN
TAHUN 2023 TAHUN 2023 N TAHUN TAHUN 2021
2022

(d) = (c) - (a) (e) (f) (g)

180 0 0 0 0
90,000
180 0 0 0 0
45,100
60 0 0 0 0
36,000
360 0 0 0 0
24,200
54 0 0 0 0
15,003
168 0 0 0 0
29,040
180 0 0 0 0
15,972
180 0 0 0 0
12,100
540 0 0 0 0
8,360
0 0 0 0 0
8,360
90 0 0 0 0
6,050
889 0 0 0 0
125,000
90 0 0 0 0
12,100
720 0 0 0 0
200,000
130 0 0 0 0
5,280
78 0 0 0 0
48,235
1,300 0 0 0 0
900
180 0 0 0 0
1,200
1,400 0 0 0 0
1,625
3,000 0 0 0 0
1,535
1,800 0 0 0 0
765
1,800 0 0 0 0
7,760
180 0 0 0 0
5,850
90 0 0 0 0
10,406
180 0 0 0 0
13,976
180 0 0 0 0
5,643
0 0 0 0 0
5,643
360 0 0 0 0
8,355
360 0 0 0 0
8,355
360 0 0 0 0
42,465
720 0 0 0 0
24,205
180 0 0 0 0
149,800
180 0 0 0 0
27,300
36 0 0 0 0
40,692
36 0 0 0 0
35,460
360 0 0 0 0
22,000
54 0 0 0 35,532 0
 DAFTAR PERMOHONAN OBAT DAN BAHAN GIGI
TAHUN 2023

NO NAMA OBAT SATUAN SISA STOK PEMAKAIAN JUMLAH

PER 31 RATA-RATA KEBUTUHAN
DESEMBER PER BULAN TAHUN 2023
2021 SELAMA 2021

(a) (b) (c) = (b) x 18

Anestetik lokal gigi kombinasi :
1 lidokain hcl 2% + epinefrin 1 :
80.000 inj 2 ml
amp 0 20 360
2 Etil klorida semprot 100 ml botol 0 3 54
3 Eugenol botol 3 1 18
4 Formokresol botol 0 0 0
5 Cavit G / Tumpatan sementara
botol 6 1 18
6 Cresofate/Cresotine Pasta botol 6 1 18
7 Cresotin Liquid II botol 10 2 36
8 Devitalisasi Pasta (non arsen)
tube 0 1 18
9 Fuji II botol 5 0 0
10 Fuji IX botol 13 2 36
Elite sement/ Polikarboksilat
11
Cement botol 5 1 18
12 Cresophene botol 0 0 0
13 Cholorophenol
Camphormenthol (CHKM) botol 5 1 18
14 Cresolformalin
(Tricresolformalin) botol 0 1 18
15 Rockles botol 0 1 18
16 Pulperyl botol 0 1 18
17 OCO botol 0 1 18
18 Etsa botol 2 1 18
19 Bonding botol 4 1 18
20 Komposit warna A3 botol 6 1 18
21 Komposit warna A2 botol 4 1 18
22 Kalsium hidroksida /Ca(OH)2/
subbase tube 4 1 18
23 Articulating paper box 18 0 0
24 Bur High speed (round, fisure,
inverted) set 40 3 54
25 Arkansas stone 0 1 18
26
Olyco disposable dental needles 1 10 180
27 Septocaine anastesi lokal amp 0 10 180
28 Jarum injeksi 1 ml biji 20 360

Jika ada tambahan tulis dibawahnya lagi

RENCANA RENCANA HARGA SATUAN JUMLAH HARGA
KEBUTUHAN PENGADAAN
TAHUN 2023 TAHUN 2023

(d) = (c) - (a) (e)

360
54
15
0

12
12
26

18
-5
23

13
0

13

18
18
18
18
16
14
12
14

14
-18

14
 18

179
180
 obat tambahan /penunjang TAHUN 2023

NO NAMA OBAT SATUAN SISA STOK PER PEMAKAIAN JUMLAH

31 DESEMBER RATA-RATA KEBUTUHAN
2021 PER BULAN TAHUN 2023
SELAMA 2021

(a) (b) (c) = (b) x 18

1 Asiklovir salep kulit Tube 5 gram 0 20 360
2 Aquadest 500 ml btl 0 5 90
3 KY Jely Tube 0 5 90
4 Ambroxol Syrup btl/60ml 0 150 2700
5 Betahistin Mesilat tab 6 mg Tablet 0 200 3600
6 Burnazin zk tube 0 5 90
7 Cefixim tablet 300 5400
8 Cetrizin tablet 10 mg Tablet 0 1500 27000
9 Cetirizin sirup btl 0 200 3600
10 combivet inhalation pcs 0 40 720
11 Doksisiklin kapsul 100mg Kapsul 0 10 180
12 Diasepam rektal 5 mg pcs 0 10 180
13 Dexocort zk tube 0 40 720
14 Ergotamin tartrat Tablet 0 0 0
15 Gentamisin salep kulit 0,1% Tube 0 50 900
16 Kalium diklofenak tablet 50 mg Tablet 0 1500 27000
17 Kloramfenikol tetes telinga 3% Botol 20 360
18 Ketokonazol krim 2 % tube 15 gram 0 50 900
19 Lidokain Injeksi 2% ampul 0 30 540
20 Metoklopramida syrup 5 mg/5ml Btl 60 ml 0 0 0
21 Meloksikam tablet 7,5 mg Tablet 0 1500 27000
22 Mutivitamin TABLET tablet 0 5000 90000
23 Mutivitamin sirup Botol 0 20 360
24 Multivitamin Herbal tablet 2500 45000
25 Multivitamin syrup herbal botol 100 1800
26 Obat batuk herbal 2000 36000
27 Ondansentron inkeksi ampul 0 3 54
28 Oksitetrasiklin salep kulit tube 5 gram 0 40 720
29 Parasetamol supp 250 pcs 0 30 540
30 Phenol gliserin tetes teliga btl 0 40 720
31 Ranitidin injeksi ampul 0 4 72
32 Sefotaxim Injeksi 1 gram Vial 0 0 0
33 Thiamfenikol kapsul 500mg Kapsul 0 50 900
34 Cazetin Drop obat sariawan Botol 15 270
34 Kaltrofen Sup Sup 5 90
35 Ketorolac injeksi ampul 4 72
36 Glukosa 40% Botol 1 18
37 Glukosa 10% Botol 1 18
38 Glukosa 5% Botol 1 18
Jika ada tambahan tulis dibawahnya lagi
RENCANA RENCANA HARGA SATUAN JUMLAH HARGA
KEBUTUHAN PENGADAAN
TAHUN 2023 TAHUN 2023

(d) = (c) - (a) (e)

360
90 0
90 0
2700 0
3600 0
90 0

27000 0
3600 0
720 0
180 0
180 0
720 0
0 0
900 0
27000 0

900 0
540 0
0 0
27000 0
90000 0
360 0

54 0
720 0
540 0
720 0
72 0
0 0
900 0
 KEBUTUHAN BAHAN LAB.TAHUN 2023

NO NAMA BARANG SATUAN jml kebutuhan Harga satuan

3
1 Tes golongan darah A botol 96,250
3
2 Tes golongan darah B botol 96,250
3
3 Tes golongan darah AB botol 96,250
3
4 Tes golongan darah D botol 180,400
540
5 Pot 20 cc buah 1,265
50
6 Tissue kotak 14,960
7 Pot urine buah 540
Jumlah Harga
 KEBUTUHAN BELANJA SARANA PENUNJANG KEFARMASIAN 2023

NO NAMA BARANG SATUAN jml kebutuhan Harga satuan

1 Klip obat besar 10 x 15 cm bungkus/100 4000 11,000
2 Klip obat tanggung 8,7 x 13 cm bungkus/100 4000 9,900
3 Klip obat kecil 7 x 10 cm bungkus/100 600 7,700
4 Sendok syrup biji 700 880
5 Kertas Perkamen bungkus 20 11,000
6 Kertas puyer ( Cetak) Pak / 1200 77,000
7 Pot salep biji 150 1,265

Jika ada tambahan tulis dibawahnya lagi

Jumlah Harga