Tahun 2022 Tahun 2022 Obat

No Obat Generik Satuan (a) (b) (c)

1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/ 16 12 0
2 Alopurinol tab 100 mg botol 25 mL
Tab 770 1720 0
3 Alopurinol tab 300 mg tablet/kapsul/ 0 0 12
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10 0 0 12
5 Aminofilin Tab 200 mg ml
tablet/kapsul/ 0 0 12
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/ 60 50 0
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/ 510 2970 2
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/ 2110 890 4
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol 36 143 0
10 ml
Amoksisilin tab 250 mg tablet/kapsul/ 0 0 12
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/ 6103 14632 0
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial 8 7 2
13 Anestetik lokal gigi kombinasi : ampul/vial 30 490 1
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/
8669 10165 0
15 aluminium hidroksida: 200 mg + botol
Antasida, kombinasi kaplet60 ml
0 204 2
16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g 0 0 12
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria 12 28 0
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/ 870 480
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab 0 0 12
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/ 0 3723 4
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/ 0 240 8
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/ 12683 16362 0
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/ 0 0 0
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/ 641 779 0
25 Atapulgit 600 mg kaplet
tablet/kapsul/ 90 526 0
26 Atropin inj 0,25 mg/ml kaplet
Ampul 0 0 12
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol 0 1 3
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/ 17 19 0
29 Betahistin tab 6 mg Plastik
tablet/kapsul/ 490 1150 1
30 Betametason krim 0,1% kaplet5 gram
tube 21 69 0
31 Bisakodil sup 10 mg Suppositoria 12 5 0
32 Bisakodil tab sal 5 mg tablet/kapsul/ 0 444 1
33 Deksametason inj 5 mg/ml kaplet
ampul/vial 67 79 0
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/ 8025 10953 0
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube 4 3 0
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial 5 0 10
37 Diazepam tab 2 mg tablet/kapsul/ 0 19 0
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial 4 198 0
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/ 0 300 0
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/ 390 500 0
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol 0 115 0
42 Domperidon tab 10 mg tablet/kapsul/ 291 574 0
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul 16 104 3
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml 4 17 0
45 Eritromisin tab 500 mg tablet/kapsul/ 0 350 4
46 Etanol 70% cairan 70% kaplet
Botol 54 31 0
47 Etil klorida semprot 100 ml Botol 23 32 0
48 Eugenol Botol 1 2 3
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml 0 0 12
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps 1450 450 0
51 Fenobarbital tab 30 mg tablet/kapsul/ 40 30 0
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial 29 278 0
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion 0 225 5
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut 0 0 12
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/ 0 0 0
56 Formokresol kaplet
Botol 0 1 6
57 Furosemid inj 10 mg/ml ampul/vial 0 0 0
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/ 180 242 0
59 Garam oralit kombinasi : kaplet
sachet 686 3063 0
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube
0 0 12
61 Gentamisin tts mata 0,3% Botol 35 79 0
62 Glass ionomer ART Botol 0 2 0
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/ 290 1260 0
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/ 0 4360 2
65 Glukosa Larutan Infus 10% kaplet
Botol 0 0 0
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml 0 0 0
67 Glukosa Larutan Infus 5% Botol 56 16 0
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/ 130 230 0
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial 9 4 0
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/ 0 5060 3
73 Haloperidol tts 2 mg/ml kaplet
botol 9 13 0
74 Hidrogen peroksida cairan 3% Botol 0 0 12
75 Hidroklorotiazid tab 25 mg tablet/kapsul/ 155 222 0
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube 14 31 0
77 Hiosina butilbromida tab 10 mg tablet/kapsul/ 300 470 0
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol 0 129 2
79 Ibuprofen tab 200 mg tablet/kapsul/ 0 2050 4
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/ 2597 7486 0
81 Isoniazid tab 100 mg kaplet
Tab 0 0 12
82 Isoniazid tab 300 mg Tab 0 0 12
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/ 123 56 0
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial 12 7 0
85 Kalsium hidroksida bubuk, Tube 0 0 12
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/ 1578 7046 0
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet 274 900 0
88 Karbamazepin Tab 200 mg Tablet 140 360 0
89 Karbogliserin tts telinga 10 % Botol 0 0 12
90 Ketokonazol tab 200 mg tablet/kapsul/ 430 535 0
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/ 834 1158 0
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/ 0 0 12
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/ 36 270 0
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube 13 62 0
95 Kloramfenikol susp 125 mg/5 botol 60 ml 0 2 6
96 ml
Kloramfenikol tetes telinga 3% Botol 23 46 0
97 Kloramfenikol tts mata 0,5% botol 13 22 0
98 Klorfeniramin tab 4 mg tablet/kapsul/ 4989 9252 0
99 Klorfenol kamfer mentol kaplet
Botol 1 1 0
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial 0 0 0
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut 700 130 0
102 Klozapin tab 25 mg selaput/kaplet
tablet 100 1490 0
103 Kodein tab 10 mg tablet/kapsul/ 90 100 0
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/ 0 150 0
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial 15 9 0
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab
174 716 0
107 kombinasi : sulfametoksazol
Kotrimoksazol kombinasi tiap 5 botol 60 mL 17 58 0
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL 0 0 12
109 Larutan mengandung Elektrolit Softbag @ 62 200 0
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml
30 490 0
111 Lidokain spray oral 10% botol 0 0 12
112 Loperamid tab 2 mg Tab 320 250 0
113 Loratadin tab 10 mg tablet/kapsul/ 232 1803 0
114 Magnesium sulfat inj 20% kaplet
ampul/vial 0 64 1
115 Magnesium sulfat inj 40% @25 ml
ampul/vial 10 65 0
116 Metformin tab 500 mg @25 ml
tablet/kapsul/ 220 1550 0
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial 275 86 0
118 Metilergometrin tab salut 0,125 tablet/kaplet 180 2010 0
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial 0 0 0
120 ml
Metoklopramid inj 5 mg/ml ampul/vial 11 9 0
121 Metoklopramid tab 10 mg tablet/kapsul/ 250 170 0
122 Metronidazol lar inf 5 mg/ml kaplet
botol 0 0 10
123 Metronidazol susp 125 mg/5 Botol @ 60 ml 0 2 10
124 ml
Metronidazol tab 500 mg tablet/kapsul/ 436 1824 0
125 Mikonazol krim 2% kaplet
tube 47 45 0
126 N-asetil sistein kaps 200 mg tablet/kapsul/ 5810 10191 0
127 NaCl 0,9% Larutan kaplet@500 ml
Botol 19 44 0
128 Natrium diklofenak tab 50 mg tablet salut 1000 2580 0
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/ 0 430 0
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial 12 21 0
131 Nistatin tab salut 500.000 UI tablet salut 0 0 12
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
1 20 4 10
156 2815 2045 3000
0 0 0 2000
0 0 0 15
0 0 0 0
5 82 22 100
330 5940 5430 8000
127 2289 179 4000
13 234 198 300
0 0 0 0
1330 23943 17840 25000
1 14 6 15
49 882 852 1200
924 16634 7965 20000
23 408 408 500
0 0 0 0
3 46 34 60
44 785 -85 500
0 0 0 0
532 9573 9573 10000
80 1440 1440 2000
1487 26774 14091 30000
0 0 0 0
71 1275 634 2000
48 861 771 1000
0 0 0 20
0 2 2 3
2 31 14 35
115 2070 1580 2000
6 113 92 120
0 8 -4 10
44 799 799 1000
7 129 62 150
996 17923 9898 20000
0 5 1 5
0 0 -5 5
2 31 31 100
18 324 320 350
27 491 491 500
45 818 428 1000
10 188 188 200
52 939 648 1500
 13 234 218 300
2 28 24 30
50 900 900 300
3 51 -3 50
3 52 29 50
0 5 4 5
0 0 0 0
41 736 -714 800
3 49 9 100
25 455 426 500
38 675 675 500
0 0 0 0
0 0 0 0
0 4 4 4
0 0 0 0
22 396 216 1000
278 5012 4326 5000
0 0 0 100
7 129 94 200
0 3 3 4
115 2062 1772 3000
484 8720 8720 10000
0 0 0 5
0 0 0 0
1 26 -30 30
21 376 246 500
0 7 -2 10
0 0 0
0 0 0
633 11385 11385 15000
1 21 12 20
0 0 0 10
20 363 208 500
3 51 37 100
43 769 469 1000
14 258 258 300
293 5271 5271 5000
681 12250 9653 15000
0 0 0
0 0 0
5 92 -31 100
1 11 -1 20
0 0 0 0
641 11530 9952 15000
82 1473 1199 2000
33 589 449 1000
0 0 0 20
49 875 445 1000
105 1895 1061 2500
0 0 0 0
25 442 406 1000
6 101 88 150
0 7 7 10
4 75 52 100
2 36 23 50
841 15140 10151 20000
0 2 1 2
0 0 0 0
12 213 -487 1000
135 2438 2338 3000
9 164 74 100
14 245 245 300
1 15 0 20
65 1172 998 2000
5 95 78 100
0 0 0 0
18 327 265 500
45 802 772 1000
0 0 0 10
23 409 89 500
164 2950 2718 4000
6 115 115 150
6 106 96 150
141 2536 2316 3000
8 141 -134 100
183 3289 3109 4000
0 0 0 0
1 15 4 20
15 278 28 500
0 0 0 5
0 0 0 20
166 2985 2549 4000
4 74 27 100
926 16676 10866 20000
4 72 53 100
235 4222 3222 5000
39 704 704 1000
2 34 22 50
0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/ 30 130
2 Alopurinol tab 100 mg botol 25 mL
Tab 11355 8165
3 Alopurinol tab 300 mg tablet/kapsul/ 0 0
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10 0 0
5 Aminofilin Tab 200 mg ml
tablet/kapsul/ 0 680
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/ 95 5
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/ 4812 13,721
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/ 1150 1,850
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol 319 481
10 ml
Amoksisilin tab 250 mg tablet/kapsul/ 0 0
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/ 7241 28482
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial 0 30
13 Anestetik lokal gigi kombinasi : ampul/vial 0 545
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/
8500 12459
15 aluminium hidroksida: 200 mg + botol
Antasida, kombinasi kaplet60 ml
0 541
16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g 0 0
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria 11 29
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/ 1584 956
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab 0 0
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/ 5000 417
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/ 300 130
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/ 39447 25753
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/ 0 0
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/ 862 1303
25 Atapulgit 600 mg kaplet
tablet/kapsul/ 0 1680
26 Atropin inj 0,25 mg/ml kaplet
Ampul 29 11
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol 0 3
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/ 23 112
29 Betahistin tab 6 mg Plastik
tablet/kapsul/ 352 5068
30 Betametason krim 0,1% kaplet5 gram
tube 13 62
31 Bisakodil sup 10 mg Suppositoria 13 27
32 Bisakodil tab sal 5 mg tablet/kapsul/ 0 184
33 Deksametason inj 5 mg/ml kaplet
ampul/vial 127 318
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/ 2124 6404
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube 20 40
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial 17 28
37 Diazepam tab 2 mg tablet/kapsul/ 180 284
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial 0 110
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/ 0 520
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/ 447 53
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol 0 278
42 Domperidon tab 10 mg tablet/kapsul/ 1563 3511
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul 22 43
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml 0 0
45 Eritromisin tab 500 mg tablet/kapsul/ 0 180
46 Etanol 70% cairan 70% kaplet
Botol 182 133
47 Etil klorida semprot 100 ml Botol 15 19
48 Eugenol Botol 0 4
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml 0 0
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps 660 320
51 Fenobarbital tab 30 mg tablet/kapsul/ 261 29
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial 183 290
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion 2300 2354
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut 0 0
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/ 0 0
56 Formokresol kaplet
Botol 2 2
57 Furosemid inj 10 mg/ml ampul/vial 189 86
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/ 660 4133
59 Garam oralit kombinasi : kaplet
sachet 3256 6322
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube
0 0
61 Gentamisin tts mata 0,3% Botol 76 132
62 Glass ionomer ART Botol 1 5
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/ 4704 14396
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/ 15211 5824
65 Glukosa Larutan Infus 10% kaplet
Botol 31 2
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml 100 64
67 Glukosa Larutan Infus 5% Botol 55 0
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/ 0 0
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial 38 102
70 Haloperidol tab 0,5 mg tablet/kapsul/ 0 0
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/ 1280 2595
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/ 0 622
73 Haloperidol tts 2 mg/ml kaplet
botol 0 0
74 Hidrogen peroksida cairan 3% Botol 15 5
75 Hidroklorotiazid tab 25 mg tablet/kapsul/ 200 953
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube 266 194
77 Hiosina butilbromida tab 10 mg tablet/kapsul/ 1427 403
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol 0 100
79 Ibuprofen tab 200 mg tablet/kapsul/ 3149 3456
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/ 5134 14536
81 Isoniazid tab 100 mg kaplet
Tab 0 0
82 Isoniazid tab 300 mg Tab 0 0
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/ 177 87
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial 36 32
85 Kalsium hidroksida bubuk, Tube 1 1
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/ 15525 19905
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet 941 1263
88 Karbamazepin Tab 200 mg Tablet 225 172
89 Karbogliserin tts telinga 10 % Botol 14 57
90 Ketokonazol tab 200 mg tablet/kapsul/ 336 164
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/ 1688 1305
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/ 0 0
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/ 4490 2510
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube 5 70
95 Kloramfenikol susp 125 mg/5 botol 60 ml 36 153
96 ml
Kloramfenikol tetes telinga 3% Botol 39 66
97 Kloramfenikol tts mata 0,5% botol 37 43
98 Klorfeniramin tab 4 mg tablet/kapsul/ 10474 8320
99 Klorfenol kamfer mentol kaplet
Botol 1 3
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial 0 0
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut 1168 1956
102 Klozapin tab 25 mg selaput/kaplet
tablet 1073 1127
103 Kodein tab 10 mg tablet/kapsul/ 0 60
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/ 0 0
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial 100 290
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab
812 2338
107 kombinasi : sulfametoksazol
Kotrimoksazol kombinasi tiap 5 botol 60 mL 147 145
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL 0 0
109 Larutan mengandung Elektrolit Softbag @ 708 4334
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml
0 100
111 Lidokain spray oral 10% botol 0 0
112 Loperamid tab 2 mg Tab 30 110
113 Loratadin tab 10 mg tablet/kapsul/ 3718 532
114 Magnesium sulfat inj 20% kaplet
ampul/vial 26 14
115 Magnesium sulfat inj 40% @25 ml
ampul/vial 26 9
116 Metformin tab 500 mg @25 ml
tablet/kapsul/ 22414 18866
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial 325 0
118 Metilergometrin tab salut 0,125 tablet/kaplet 790 210
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial 0 0
120 ml
Metoklopramid inj 5 mg/ml ampul/vial 499 191
121 Metoklopramid tab 10 mg tablet/kapsul/ 281 419
122 Metronidazol lar inf 5 mg/ml kaplet
botol 0 50
123 Metronidazol susp 125 mg/5 Botol @ 60 ml 0 0
124 ml
Metronidazol tab 500 mg tablet/kapsul/ 283 1037
125 Mikonazol krim 2% kaplet
tube 71 25
126 N-asetil sistein kaps 200 mg tablet/kapsul/ 4734 14328
127 NaCl 0,9% Larutan kaplet@500 ml
Botol 9 91
128 Natrium diklofenak tab 50 mg tablet salut 1707 2393
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/ 640 360
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial 0 30
131 Nistatin tab salut 500.000 UI tablet salut 0 0
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet 0 0
133 Oksimetazolin tts hidung botol @ 10 mL 0 0
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL 0 0
135 0,050%
Oksitetrasiklin 1% Salep Mata tube 0 0
136 Oksitosin inj 10 UI/ml ampul/vial 216 264
137 Omeprazol inj 40 mg/10 ml ampul/vial 0 90
138 Omeprazol kaps 20 mg tablet/kapsul/ 2295 4275
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol 1219 678
140 Parasetamol tab 500 mg tablet/kapsul/ 27301 37699
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol 0 80
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
12 213 183
742 13361 2006
0 0 0
0 0 0
62 1113 1113
0 8 -87
1247 22453 17641
168 3027 1877
44 787 468
0 0 0
2589 46607 39366
3 49 49
50 892 892
1133 20387 11887
49 885 885
0 0 0
3 47 36
87 1564 -20
0 0 0
38 682 -4318
12 213 -87
2341 42141 2694
0 0 0
118 2132 1270
153 2749 2749
1 18 -11
0 5 5
10 183 160
461 8293 7941
6 101 88
2 44 31
17 301 301
29 520 393
582 10479 8355
4 65 45
3 46 29
26 465 285
10 180 180
47 851 851
5 87 -360
25 455 455
319 5745 4182
 4 70 48
0 0 0
16 295 295
12 218 36
2 31 16
0 7 7
0 0 0
29 524 -136
3 47 -214
26 475 292
214 3852 1552
0 0 0
0 0 0
0 3 1
8 141 -48
376 6763 6103
575 10345 7089
0 0 0
12 216 140
0 8 7
1309 23557 18853
529 9530 -5681
0 3 -28
6 105 5
0 0 -55
0 0 0
9 167 129
0 0 0
236 4246 2966
57 1018 1018
0 0 0
0 8 -7
87 1559 1359
18 317 51
37 659 -768
9 164 164
314 5655 2506
1321 23786 18652
0 0 0
0 0 0
8 142 -35
3 52 16
0 2 1
1810 32572 17047
115 2067 1126
16 281 56
5 93 79
15 268 -68
119 2135 447
0 0 0
228 4107 -383
6 115 110
14 250 214
6 108 69
4 70 33
756 13615 3141
0 5 4
0 0 0
178 3201 2033
102 1844 771
5 98 98
0 0 0
26 475 375
213 3826 3014
13 237 90
0 0 0
394 7092 6384
9 164 164
0 0 0
10 180 150
48 871 -2847
1 23 -3
1 15 -11
1715 30872 8458
0 0 -325
19 344 -446
0 0 0
17 313 -186
38 686 405
5 82 82
0 0 0
94 1697 1414
2 41 -30
1303 23446 18712
8 149 140
218 3916 2209
 33 589 -51
3 49 49
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
24 432 216
8 147 147
389 6995 4700
62 1109 -110
3427 61689 34388
7 131 131
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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0 0 0
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0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/ 40
2 Alopurinol tab 100 mg botol 25 mL
Tab 850
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/ 158
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/ 3815
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol 215
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/ 14292
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/
11264
15 aluminium hidroksida: 200 mg + botol
Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g 50
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria 59
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/ 280
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/ 610
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/ 12208
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/ 5758
26 Atropin inj 0,25 mg/ml kaplet
Ampul 5
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/ 670
30 Betametason krim 0,1% kaplet5 gram
tube 13
31 Bisakodil sup 10 mg Suppositoria 8
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial 19
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/ 11220
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube 6
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial 3
37 Diazepam tab 2 mg tablet/kapsul/ 37
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/ 2052
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul 15
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol 117
47 Etil klorida semprot 100 ml Botol 2
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial 120
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion 590
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet 678
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol 80

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/ 14942
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/ 14574
65 Glukosa Larutan Infus 10% kaplet
Botol 37
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml 16
67 Glukosa Larutan Infus 5% Botol 19
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube 42
77 Hiosina butilbromida tab 10 mg tablet/kapsul/ 780
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/ 4142
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab 70
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/ 75
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial 10
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/ 4762
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet 720
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/ 318
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/ 1404
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/ 284
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube 6
95 Kloramfenikol susp 125 mg/5 botol 60 ml 50
96 ml
Kloramfenikol tetes telinga 3% Botol 14
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab
896
107 kombinasi : sulfametoksazol
Kotrimoksazol kombinasi tiap 5 botol 60 mL 83
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml
869
111 Lidokain spray oral 10% botol
112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/ 3730
114 Magnesium sulfat inj 20% kaplet
ampul/vial 10
115 Magnesium sulfat inj 40% @25 ml
ampul/vial 36
116 Metformin tab 500 mg @25 ml
tablet/kapsul/ 8429
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial 319
118 Metilergometrin tab salut 0,125 tablet/kaplet 100
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial 5
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/ 493
125 Mikonazol krim 2% kaplet
tube 39
126 N-asetil sistein kaps 200 mg tablet/kapsul/ 2129
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut 7825
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial 7
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet 37
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube 21
136 Oksitosin inj 10 UI/ml ampul/vial 111
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/ 623
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol 403
140 Parasetamol tab 500 mg tablet/kapsul/ 14283
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g 8
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl 830
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/ 570
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/ 294
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps 150
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak 3678
200.000 UI
157 Ringer Laktat Larutan Botol 292
158 Risperidon tab sal 2 mg tablet/kapsul/ 1123
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 -40
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0 0 -12208
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0 0 -5
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0 0 -6
0 0 -3
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0 0 -15
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0 0 -720
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0 0 -318
0 0 -1404
0 0 0
0 0 -284
0 0 -6
0 0 -50
0 0 -14
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0 0 -83
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0 0 0
0 0 -869
0 0 0
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0 0 -3730
0 0 -10
0 0 -36
0 0 -8429
0 0 -319
0 0 -100
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0 0 -39
0 0 -2129
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0 0 0
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0 0 -403
0 0 -14283
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0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
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0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/ 25 4
2 Alopurinol tab 100 mg botol 25 mL
Tab 3385 4684
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/ 75 85
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/ 9940 8690
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/ 5590 8510
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol 34 66
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/ 28270 19914
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/
10976 13090
15 aluminium hidroksida: 200 mg + botol
Antasida, kombinasi kaplet60 ml
0 134
16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g 14 45
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria 20 84
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/ 5 85
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/ 0 110
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/ 19195 25246
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/ 157 849
25 Atapulgit 600 mg kaplet
tablet/kapsul/ 2997 1021
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol 1 1
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/ 72 69
29 Betahistin tab 6 mg Plastik
tablet/kapsul/ 750 1450
30 Betametason krim 0,1% kaplet5 gram
tube 104 191
31 Bisakodil sup 10 mg Suppositoria 9 11
32 Bisakodil tab sal 5 mg tablet/kapsul/ 35 205
33 Deksametason inj 5 mg/ml kaplet
ampul/vial 10 4
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/ 9232 11049
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial 1 1
37 Diazepam tab 2 mg tablet/kapsul/ 112 61
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial 0 138
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/ 0 140
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/ 40 365
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol 0 7
42 Domperidon tab 10 mg tablet/kapsul/ 100 700
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul 14 21
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol 24 24
47 Etil klorida semprot 100 ml Botol 4 13
48 Eugenol Botol 1 0
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/ 100 0
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial 5 4
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion 245 700
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol 1 0
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/ 290 252
59 Garam oralit kombinasi : kaplet
sachet 3940 3484
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol 34 149

62 Glass ionomer ART Botol 1 3
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/ 5164 5630
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/ 4013 7412
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml 0 1
67 Glukosa Larutan Infus 5% Botol 11 1
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/ 0 90
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/ 2329 2530
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/ 0 1875 4
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol 0 8
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube 67 120
77 Hiosina butilbromida tab 10 mg tablet/kapsul/ 309 350
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/ 1125 4819
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/ 205 1875
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/ 0 110
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/ 17361 19719
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet 3687 1483
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/ 270 670
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/ 218 482
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/ 156 1222
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube 43 49
95 Kloramfenikol susp 125 mg/5 botol 60 ml 0 2
96 ml
Kloramfenikol tetes telinga 3% Botol 8 36
97 Kloramfenikol tts mata 0,5% botol 0 20
98 Klorfeniramin tab 4 mg tablet/kapsul/ 12462 17583
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut 3860 3420
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/ 60 40
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab
207 435
107 kombinasi : sulfametoksazol
Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @ 9 19
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml
102 278
111 Lidokain spray oral 10% botol
112 Loperamid tab 2 mg Tab 880 120
113 Loratadin tab 10 mg tablet/kapsul/ 581 1789
114 Magnesium sulfat inj 20% kaplet
ampul/vial 0 8
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/ 13825 9530
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial 207 3
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 7 -18
426 7665 4280
0 0 0
0 0 0
0 0 0
8 139 64
790 14220 4280
774 13925 8335
6 108 74
0 0 0
1810 32587 4317
0 0 0
0 0 0
1190 21420 10444
12 219 219
4 74 60
8 137 117
8 139 134
0 0 0
10 180 180
0 0 0
2295 41312 22117
0 0 0
77 1389 1232
93 1671 -1326
0 0 0
0 2 1
6 113 41
132 2373 1623
17 313 209
1 18 9
19 335 300
0 7 -3
1004 18080 8848
0 0 0
0 2 1
6 100 -12
13 226 226
13 229 229
33 597 557
1 11 11
64 1145 1045
 2 34 20
0 0 0
0 0 0
2 39 15
1 21 17
0 0 -1
0 0 0
0 0 0
0 0 -100
0 7 2
64 1145 900
0 0 0
0 0 0
0 0 -1
0 0 0
23 412 122
317 5701 1761
0 0 0
14 244 210
0 5 4
512 9213 4049
674 12129 8116
0 0 0
0 2 2
0 2 -9
8 147 147
0 0 0
0 0 0
230 4140 1811
268 4821 4821
0 0 0
1 13 13
0 0 0
11 196 129
32 573 264
0 0 0
438 7886 6761
170 3068 2863
0 0 0
0 0 0
10 180 180
0 0 0
0 0 0
1793 32267 14906
135 2427 -1260
0 0 0
0 0 0
61 1096 826
44 789 571
0 0 0
111 2000 1844
4 80 37
0 3 3
3 59 51
2 33 33
1598 28772 16310
0 0 0
0 0 0
311 5596 1736
0 0 0
4 65 5
0 0 0
0 0 0
40 712 505
0 0 0
0 0 0
2 31 22
25 455 353
0 0 0
11 196 -684
163 2927 2346
1 13 13
0 0 0
866 15595 1770
0 5 -202
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/ 0
2 Alopurinol tab 100 mg botol 25 mL
Tab 4505 4888
3 Alopurinol tab 300 mg tablet/kapsul/ 0 0
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10 0 0
5 Aminofilin Tab 200 mg ml
tablet/kapsul/ 0 0
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/ 140 60
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/ 5030 16060
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/ 0
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol 109 287
10 ml
Amoksisilin tab 250 mg tablet/kapsul/ 0
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/ 4130 14834
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial 0
13 Anestetik lokal gigi kombinasi : ampul/vial 392 356
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/
5215 8731
15 aluminium hidroksida: 200 mg + botol
Antasida, kombinasi kaplet60 ml
0 209
16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g 0 54
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria 19 59
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/ 1067 840
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab 0 500
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/ 1900 2307
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/ 110 280
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/ 4386 14849
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/ 0
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/ 1790 1505
25 Atapulgit 600 mg kaplet
tablet/kapsul/ 670 858
26 Atropin inj 0,25 mg/ml kaplet
Ampul 0
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol 1 0
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/ 16 113
29 Betahistin tab 6 mg Plastik
tablet/kapsul/ 857 1873
30 Betametason krim 0,1% kaplet5 gram
tube 0 108
31 Bisakodil sup 10 mg Suppositoria 16 31
32 Bisakodil tab sal 5 mg tablet/kapsul/ 72 318
33 Deksametason inj 5 mg/ml kaplet
ampul/vial 26 22
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/ 1389 9818
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube 5 4
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial 0 4
37 Diazepam tab 2 mg tablet/kapsul/ 241 354
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial 0 38
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/ 0 0
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/ 270 380
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol 28 55
42 Domperidon tab 10 mg tablet/kapsul/ 81 779
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul 12 29
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml 0 0
45 Eritromisin tab 500 mg tablet/kapsul/ 100 0
46 Etanol 70% cairan 70% kaplet
Botol 173 69
47 Etil klorida semprot 100 ml Botol 18 23
48 Eugenol Botol 0 0
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml 0 0
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps 260 840
51 Fenobarbital tab 30 mg tablet/kapsul/ 0 0
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial 17 203
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion 440 701
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut 0 0
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/ 0 0
56 Formokresol kaplet
Botol 0 0
57 Furosemid inj 10 mg/ml ampul/vial 0 0
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/ 45 1321
59 Garam oralit kombinasi : kaplet
sachet 2506 3077
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube
0 0
61 Gentamisin tts mata 0,3% Botol 45 225
62 Glass ionomer ART Botol 1 0
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/ 18503 8572
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/ 4955 4975
65 Glukosa Larutan Infus 10% kaplet
Botol 0 0
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml 5 0
67 Glukosa Larutan Infus 5% Botol 0 0
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/ 180 120
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial 0 10
70 Haloperidol tab 0,5 mg tablet/kapsul/ 0 0
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/ 1320 1115
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/ 0 3820
73 Haloperidol tts 2 mg/ml kaplet
botol 0 0
74 Hidrogen peroksida cairan 3% Botol 1 0
75 Hidroklorotiazid tab 25 mg tablet/kapsul/ 25 775
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube 109 94
77 Hiosina butilbromida tab 10 mg tablet/kapsul/ 756 2674
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol 44 123
79 Ibuprofen tab 200 mg tablet/kapsul/ 6287 6255
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/ 3000 8108
81 Isoniazid tab 100 mg kaplet
Tab 0 0
82 Isoniazid tab 300 mg Tab 0 0
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/ 0 250
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial 0 10
85 Kalsium hidroksida bubuk, Tube 1 0
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/ 2729 5361
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet 3980 1150
88 Karbamazepin Tab 200 mg Tablet 1120 2380
89 Karbogliserin tts telinga 10 % Botol 0 0
90 Ketokonazol tab 200 mg tablet/kapsul/ 372 835
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/ 756 2164
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/ 0 0
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/ 160 490
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube 3 68
95 Kloramfenikol susp 125 mg/5 botol 60 ml 26 25
96 ml
Kloramfenikol tetes telinga 3% Botol 55 81
97 Kloramfenikol tts mata 0,5% botol 62 20
98 Klorfeniramin tab 4 mg tablet/kapsul/ 8582 14718
99 Klorfenol kamfer mentol kaplet
Botol 0 0
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial 0 0
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut 3398 2116
102 Klozapin tab 25 mg selaput/kaplet
tablet 1375 925
103 Kodein tab 10 mg tablet/kapsul/ 0 195
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/ 0 0
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial 24 6
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab
676 1794
107 kombinasi : sulfametoksazol
Kotrimoksazol kombinasi tiap 5 botol 60 mL 59 57
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL 0 0
109 Larutan mengandung Elektrolit Softbag @ 72 117
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml
0 0
111 Lidokain spray oral 10% botol 0 0
112 Loperamid tab 2 mg Tab 360 272
113 Loratadin tab 10 mg tablet/kapsul/ 5960 2482
114 Magnesium sulfat inj 20% kaplet
ampul/vial 5 10
115 Magnesium sulfat inj 40% @25 ml
ampul/vial 5 5
116 Metformin tab 500 mg @25 ml
tablet/kapsul/ 10095 10235
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial 226 59
118 Metilergometrin tab salut 0,125 tablet/kaplet 157 173
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial 0 0
120 ml
Metoklopramid inj 5 mg/ml ampul/vial 0 0
121 Metoklopramid tab 10 mg tablet/kapsul/ 100 0
122 Metronidazol lar inf 5 mg/ml kaplet
botol 0 0
123 Metronidazol susp 125 mg/5 Botol @ 60 ml 0 0
124 ml
Metronidazol tab 500 mg tablet/kapsul/ 1238 1716
125 Mikonazol krim 2% kaplet
tube 36 76
126 N-asetil sistein kaps 200 mg tablet/kapsul/ 915 9569
127 NaCl 0,9% Larutan kaplet@500 ml
Botol 66 14
128 Natrium diklofenak tab 50 mg tablet salut 810 7015
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/ 170 330
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial 10 24
131 Nistatin tab salut 500.000 UI tablet salut 0 0
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet 89 106
133 Oksimetazolin tts hidung botol @ 10 mL 0 0
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL 0 0
135 0,050%
Oksitetrasiklin 1% Salep Mata tube 0 127
136 Oksitosin inj 10 UI/ml ampul/vial 106 208
137 Omeprazol inj 40 mg/10 ml ampul/vial 0 0
138 Omeprazol kaps 20 mg tablet/kapsul/ 4110 3285
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol 126 271
140 Parasetamol tab 500 mg tablet/kapsul/ 5714 21235
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol 0 0
142 Pasta devitalisasi (non arsen) Tube 0 0
143 Pasta pengisi saluran akar Tube 0 0
144 (pasta)
Perak sulfadiazin krim 1% Tube 0 0
145 Permetrin krim 5 % Tube 10 g 44 214
146 Pirantel pamoat tab scored tablet/kapsul/ 0 0
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl 0 0
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL 37 49
149 Povidon iodin lar 100 mg/ml Botol 300 ml 20 0
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/ 528 1842
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/ 210 620
153 Propranolol tab 10 mg kaplet
tablet/kapsul/ 145 155
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/ 903 1742
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps 0 1400
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak 0 6000
200.000 UI
157 Ringer Laktat Larutan Botol 72 117
158 Risperidon tab sal 2 mg tablet/kapsul/ 977 3623
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram 13 68
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/ 0 607
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol 0 0
162 ml
Serum anti bisa ular : A.B.U. I Vial 5 1
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul 7 7
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL 4 21
165 Sianokobalamin (vitamin B12) ampul/vial 0 0
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/ 4330 5910
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/ 0 0
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut 440 4724
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/ 5 475
170 Tetrakain tts mata 0,5% kaplet
Botol 0 0
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/ 2964 4240
kaplet
172 Urea krim 10 % Tube/pot 0 0
173 Valproat sir 250 mg/5 ml botol @ 120 0 0
174 Vitamin B kompleks ml
tablet 3677 13852
175 Vitamin C 500 mg minimal non Tablet/ 3850 2150
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol 6 12
177 Zinc sir 20 mg/5 ml botol 512 213
178 Zinc tab disp 20 mg tablet 5160 1744
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
444 7999 3494
0 0 0
0 0 0
0 0 0
5 98 -42
1460 26280 21250
0 0 0
26 470 361
0 0 0
1349 24274 20144
0 0 0
32 583 191
794 14287 9072
19 342 342
5 88 88
5 97 78
76 1375 308
45 818 818
210 3775 1875
25 458 348
1350 24298 19912
0 0 0
137 2463 673
78 1404 734
0 0 0
0 0 -1
10 185 169
170 3065 2208
10 177 177
3 51 35
29 520 448
2 36 10
893 16066 14677
0 7 2
0 7 7
32 579 338
3 62 62
0 0 0
35 622 352
5 90 62
71 1275 1194
 3 47 35
0 0 0
0 0 -100
6 113 -60
2 38 20
0 0 0
0 0 0
76 1375 1115
0 0 0
18 332 315
64 1147 707
0 0 0
0 0 0
0 0 0
0 0 0
120 2162 2117
280 5035 2529
0 0 0
20 368 323
0 0 -1
779 14027 -4476
452 8141 3186
0 0 0
0 0 -5
0 0 0
11 196 16
1 16 16
0 0 0
101 1825 505
347 6251 6251
0 0 0
0 0 -1
70 1268 1243
9 154 45
243 4376 3620
11 201 157
569 10235 3948
737 13268 10268
0 0 0
0 0 0
23 409 409
1 16 16
0 0 -1
487 8773 6044
105 1882 -2098
216 3895 2775
0 0 0
76 1366 994
197 3541 2785
0 0 0
45 802 642
6 111 108
2 41 15
7 133 78
2 33 -29
1338 24084 15502
0 0 0
0 0 0
192 3463 65
84 1514 139
18 319 319
0 0 0
1 10 -14
163 2936 2260
5 93 34
0 0 0
11 191 119
0 0 0
0 0 0
25 445 85
226 4061 -1899
1 16 11
0 8 3
930 16748 6653
5 97 -129
16 283 126
0 0 0
0 0 0
0 0 -100
0 0 0
0 0 0
156 2808 1570
7 124 88
870 15658 14743
1 23 -43
638 11479 10669
 30 540 370
2 39 29
0 0 0
10 173 84
0 0 0
0 0 0
12 208 208
19 340 234
0 0 0
299 5375 1265
25 443 317
1930 34748 29034
0 0 0
0 0 0
0 0 0
0 0 0
19 350 306
0 0 0
0 0 0
4 80 43
0 0 -20
0 0 0
167 3014 2486
56 1015 805
14 254 109
158 2851 1948
127 2291 2291
545 9818 9818
11 191 119
329 5929 4952
6 111 98
55 993 993
0 0 0
0 2 -3
1 11 4
2 34 30
0 0 0
537 9671 5341
0 0 0
429 7730 7290
43 777 772
0 0 0
385 6938 3974
 0 0 0
0 0 0
1259 22667 18990
195 3518 -332
1 20 14
19 349 -163
159 2854 -2306
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
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0 0 0
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0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/ 53 85
2 Alopurinol tab 100 mg botol 25 mL
Tab 940 1446
3 Alopurinol tab 300 mg tablet/kapsul/ 326 1174
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10 12
5 Aminofilin Tab 200 mg ml
tablet/kapsul/ 518 282
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/ 2399 385
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/ 983 3083
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/ 732 1676
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol 293 400
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/ 15061 22177
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial 50 660 1
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/ 336 19654 1
15 aluminium hidroksida: 200 mg + botol
Antasida, kombinasi kaplet60 ml 800
16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g 31 1
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria 160
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/ 1024 3
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab 1430 6
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/ 230 8
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/ 9437 21041 1
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/ 250 230
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/ 129 431
25 Atapulgit 600 mg kaplet
tablet/kapsul/ 100 1952 1
26 Atropin inj 0,25 mg/ml kaplet
Ampul 5 35
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol 1
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/ 37 3
29 Betahistin tab 6 mg Plastik
tablet/kapsul/ 496 948 2
30 Betametason krim 0,1% kaplet5 gram
tube 156 2
31 Bisakodil sup 10 mg Suppositoria 15 60
32 Bisakodil tab sal 5 mg tablet/kapsul/ 60 189
33 Deksametason inj 5 mg/ml kaplet
ampul/vial 123 479
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/ 2330 11020
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube 8 27
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial 50 24
37 Diazepam tab 2 mg tablet/kapsul/ 368 47
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial 476 3
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/ 760 3
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/ 532 1501
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol 34 121
42 Domperidon tab 10 mg tablet/kapsul/ 505 1353
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul 15 100 2
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml 30
45 Eritromisin tab 500 mg tablet/kapsul/ 68 20
46 Etanol 70% cairan 70% kaplet
Botol 169 69
47 Etil klorida semprot 100 ml Botol 3 13 1
48 Eugenol Botol 1
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps 1710 6792 1
51 Fenobarbital tab 30 mg tablet/kapsul/ 1516 5
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial 88 132
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion 549 246
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial 18 59
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/ 372 231
59 Garam oralit kombinasi : kaplet
sachet 5785 2980
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube 12
61 Gentamisin tts mata 0,3% Botol 55 78 1
62 Glass ionomer ART Botol 1
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/ 1000 1
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/ 790 2110 1
65 Glukosa Larutan Infus 10% kaplet
Botol 202 45
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml 5 47
67 Glukosa Larutan Infus 5% Botol 134 195
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/ 30 70
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial 33 2
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/ 3838 1776
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/ 655 5
73 Haloperidol tts 2 mg/ml kaplet
botol 3
74 Hidrogen peroksida cairan 3% Botol 9 27
75 Hidroklorotiazid tab 25 mg tablet/kapsul/ 49 151
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube 22 76 2
77 Hiosina butilbromida tab 10 mg tablet/kapsul/ 353 647 2
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol 25 26
79 Ibuprofen tab 200 mg tablet/kapsul/ 344 156
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/ 1000
81 Isoniazid tab 100 mg kaplet
Tab 20 80
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/ 749 70
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial 35 15
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/ 3038 8692
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet 1214 1
88 Karbamazepin Tab 200 mg Tablet 925 2910 1
89 Karbogliserin tts telinga 10 % Botol 31 24 1
90 Ketokonazol tab 200 mg tablet/kapsul/ 349 385 2
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/ 450
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/ 1110 70
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube 32 31
95 Kloramfenikol susp 125 mg/5 botol 60 ml 20 32
96 ml
Kloramfenikol tetes telinga 3% Botol 74 26
97 Kloramfenikol tts mata 0,5% botol 14 6
98 Klorfeniramin tab 4 mg tablet/kapsul/ 1144 6269 1
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut 1261 3383
102 Klozapin tab 25 mg selaput/kaplet
tablet 944 1926 2
103 Kodein tab 10 mg tablet/kapsul/ 143 95
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/ 381
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial 62 2
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab 80 398 1
107 kombinasi : sulfametoksazol
Kotrimoksazol kombinasi tiap 5 botol 60 mL 22 62
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL 8 1
109 Larutan mengandung Elektrolit Softbag @ 806
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab 210 7
113 Loratadin tab 10 mg tablet/kapsul/ 532 3
114 Magnesium sulfat inj 20% kaplet
ampul/vial 16 30 1
115 Magnesium sulfat inj 40% @25 ml
ampul/vial 12 34
116 Metformin tab 500 mg @25 ml
tablet/kapsul/ 487 3156 2
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial 190
118 Metilergometrin tab salut 0,125 tablet/kaplet 50 130
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial 360 4
121 Metoklopramid tab 10 mg tablet/kapsul/ 208 2
122 Metronidazol lar inf 5 mg/ml kaplet
botol 14 5
123 Metronidazol susp 125 mg/5 Botol @ 60 ml 30 3
124 ml
Metronidazol tab 500 mg tablet/kapsul/ 30 666 3
125 Mikonazol krim 2% kaplet
tube 35 136 1
126 N-asetil sistein kaps 200 mg tablet/kapsul/ 1100 5841 1
127 NaCl 0,9% Larutan kaplet@500 ml
Botol 253 530
128 Natrium diklofenak tab 50 mg tablet salut 6989 3
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/ 43 48
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial 17 14
131 Nistatin tab salut 500.000 UI tablet salut 300 55
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet 332
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube 48 17
136 Oksitosin inj 10 UI/ml ampul/vial 161 182
137 Omeprazol inj 40 mg/10 ml ampul/vial 42 83
138 Omeprazol kaps 20 mg tablet/kapsul/ 1865 5265 1
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol 126 371
140 Parasetamol tab 500 mg tablet/kapsul/ 5743 26257
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol 14
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube 8 9
145 Permetrin krim 5 % Tube 10 g 17 18
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl 1375 5901
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL 17 27 1
149 Povidon iodin lar 100 mg/ml Botol 300 ml 9 11
150 Povidon iodin lar obat kumur Botol 16 14
151 1%
Prednison tab 5 mg tablet/kapsul/ 1048 3475 1
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/ 440 760
153 Propranolol tab 10 mg kaplet
tablet/kapsul/ 431 769
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/ 332 4680 2
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps 538
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak 1074 6521
200.000 UI
157 Ringer Laktat Larutan Botol 293 4008 1
158 Risperidon tab sal 2 mg tablet/kapsul/ 836 1764
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram 11 31
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/ 144 6
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol 10 19
162 ml
Serum anti bisa ular : A.B.U. I Vial 7 32
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul 26 59
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL 50 3
165 Sianokobalamin (vitamin B12) ampul/vial 15 70
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/ 275 2925 1
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/ 790 10
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut 638 2421
mg
169 Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/ 118 3
170 Tetrakain tts mata 0,5% kaplet
Botol 10
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/ 671 990 6
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120 25 5
174 Vitamin B kompleks ml
tablet 143 1933 6
175 Vitamin C 500 mg minimal non Tablet/ 1000 4
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol 4 7
177 Zinc sir 20 mg/5 ml botol 115 214
178 Zinc tab disp 20 mg tablet 4901 2327
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
8 139 86 80
131 2366 1426 1500
107 1921 1595 1600
0 0 0 30
26 461 -57
35 630 -1769 300 ed Feb 2023
280 5045 4062 4000
152 2743 2011 2000
36 655 362 300
0 0 0
2016 36290 21229 21500
0 0 0
66 1188 1138 1200
1965 35377 35041 35000
73 1309 1309 1000
0 2 -29
15 262 262 260
128 2304 2304 2500
286 5148 5148
77 1380 1380 5000
0 0 0
2104 37874 28437 30000
21 376 126 200
39 705 576 600
195 3514 3414 3500
3 57 52 30
0 2 2 2
5 83 83 100
105 1896 1400 1400 ed des 2022
17 312 312 300
5 98 83 80
17 309 249 250
44 784 661 700
1002 18033 15703 16000
2 44 36 40
2 39 -11
4 77 -291
60 1071 1071 600
95 1710 1710 2000
136 2456 1924 1900
11 198 164 150
123 2214 1709 1700
 11 200 185 150
0 0 -30
2 33 -35
6 113 -56 100
1 23 20 25
0 2 2 2
0 0 0
679 12226 10516 800 jika 30mg 10500
253 4548 4548 4500
12 216 128 150
22 403 -146 200
0 0 0
0 0 0
0 0 0
5 97 79
21 378 6
271 4876 -909 obat program
1 20 20 25
8 140 85 100
0 2 2 2
100 1800 1800 1800
211 3798 3008 3000
4 74 -128
4 77 72 70
18 319 185 180
6 115 85 100
0 3 -30
0 0 0
161 2906 -932 1000
109 1965 1965 1900
0 0 -3
2 44 35 35
14 247 198 200
8 152 130 120
72 1294 941 1000
2 43 18 20
14 255 -89 500
91 1636 1636 2000
7 131 111 ed
0 0 0
6 115 -634
1 25 -10
0 0 0 1
790 14223 11185 15000
121 2185 2185 2500
291 5238 4313 5000
2 43 12 25 ed des 2022
43 770 421 400
0 0 -450
0 0 0
6 115 -995
3 51 19 25
3 52 32 30
2 43 -31
1 10 -4 25
627 11284 10140 7000
0 0 0 1
0 0 0
308 5536 4275 5000
214 3852 2908 3000
9 155 12
0 0 -381 ed
7 124 124 200
40 716 636 700
6 101 79 70
0 2 -6
73 1319 1319 1320
0 0 0
0 0 0
53 945 945 900
67 1197 1197 1500
3 54 38 34
3 56 44 34
351 6312 5825 6000
0 0 -190
12 213 163 200
0 0 0
51 926 926 500
23 416 416 400
2 42 42 30
4 68 68 50
83 1499 1469 2000
14 245 210 200
584 10514 9414 10000
48 867 614 620
874 15725 15725 16000
 4 79 36 200
1 23 6
5 90 -210
0 0 -332
0 0 0
0 0 0
2 28 -20
17 298 137 200
8 136 94 90
527 9477 7612 8000
34 607 481 450
2387 42966 37223 35000
1 23 23 25
0 0 0 1
0 0 0 1
1 15 7 10
2 29 12 20
0 0 0
536 9656 8281 8500
3 49 32 35
1 18 9 10
1 23 7 15
348 6255 5207 5000
69 1244 804 800
70 1258 827 900
520 9360 9028 9000
49 880 880 obat program
593 10671 9597 obat program
401 7214 6921 6900
160 2887 2051 3000
3 51 40 48
29 518 518 500
2 31 21 20
3 52 45 45
5 97 71 80
6 113 113 100
6 115 100 50
293 5265 4990 5000
1 16 -774 1000
220 3962 3324 3500
15 266 266 100
1 16 16 10
198 3564 2893 5000
 0 0 0
0 8 -17
387 6959 6816 8000
143 2571 2571 5000
1 11 7
19 350 235 obat program
212 3808 -1093 obat program
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
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0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/ 272 203 0
2 Alopurinol tab 100 mg botol 25 mL
Tab 2541 13264 0
3 Alopurinol tab 300 mg tablet/kapsul/ 0 0 0
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10 0 0 11
5 Aminofilin Tab 200 mg ml
tablet/kapsul/ 0 1000 6
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/ 57 41 0
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/ 10839 10968 0
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/ 2148 15556 0
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol 295 611 0
10 ml
Amoksisilin tab 250 mg tablet/kapsul/ 0 0 11
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/ 33634 37425 0
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial 30 0 0
13 Anestetik lokal gigi kombinasi : ampul/vial 419 829 0
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/
5585 27438 0
15 aluminium hidroksida: 200 mg + botol
Antasida, kombinasi kaplet60 ml
0 1635 0
16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g 18 91 0
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria 45 251 0
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/ 431 1546 1
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab 0 2251 8
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/ 0 2251 3
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/ 415 190 0
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/ 17808 48513 0
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/ 290 810 0
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/ 73 1179
25 Atapulgit 600 mg kaplet
tablet/kapsul/ 1526 2890 0
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol 2 4 0
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/ 50 149 0
29 Betahistin tab 6 mg Plastik
tablet/kapsul/ 2012 3738 0
30 Betametason krim 0,1% kaplet5 gram
tube 22 211 0
31 Bisakodil sup 10 mg Suppositoria 11 14 0
32 Bisakodil tab sal 5 mg tablet/kapsul/ 100 75 0
33 Deksametason inj 5 mg/ml kaplet
ampul/vial 156 216 0
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/ 2728 15178 0
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube 11 29 0
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial 7 2 0
37 Diazepam tab 2 mg tablet/kapsul/ 141 198 0
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial 0 125 1
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/ 0 1367 1
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/ 1000 4534 0
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol 0 508 1
42 Domperidon tab 10 mg tablet/kapsul/ 1359 2337 0
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul 10 55 3
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/ 0 604 2
46 Etanol 70% cairan 70% kaplet
Botol 224 135 0
47 Etil klorida semprot 100 ml Botol 11 12 0
48 Eugenol Botol 2 3 0
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps 2340 660 0
51 Fenobarbital tab 30 mg tablet/kapsul/ 312 378 0
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial 372 448 0
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion 1313 2771 0
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol 1 3 0
57 Furosemid inj 10 mg/ml ampul/vial 43 25 0
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/ 311 1764 0
59 Garam oralit kombinasi : kaplet
sachet 3345 3810 0
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol 85 198 0

62 Glass ionomer ART Botol 3 4 0
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/ 4583 16465 0
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/ 8112 12758 0
65 Glukosa Larutan Infus 10% kaplet
Botol 33 14 0
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml 0 83 1
67 Glukosa Larutan Infus 5% Botol 85 26 0
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/ 114 501 0
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/ 3257 4383 0
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/ 0 4005 3
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol 4 3 5
75 Hidroklorotiazid tab 25 mg tablet/kapsul/ 164 391 0
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube 70 276 0
77 Hiosina butilbromida tab 10 mg tablet/kapsul/ 3248 2090 0
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol 0 337 1
79 Ibuprofen tab 200 mg tablet/kapsul/ 5487 18520 0
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/ 4066 8352 0
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/ 294 181 0
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial 10 10 0
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/ 4326 20222 0
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet 5177 7796 0
88 Karbamazepin Tab 200 mg Tablet 160 960 0
89 Karbogliserin tts telinga 10 % Botol 10 122 0
90 Ketokonazol tab 200 mg tablet/kapsul/ 302 1323 0
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/ 440 1580 0
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/ 394 5267 0
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube 12 197 0
95 Kloramfenikol susp 125 mg/5 botol 60 ml 40 192 0
96 ml
Kloramfenikol tetes telinga 3% Botol 19 51 0
97 Kloramfenikol tts mata 0,5% botol 20 32 5
98 Klorfeniramin tab 4 mg tablet/kapsul/ 8194 23675 0
99 Klorfenol kamfer mentol kaplet
Botol 1 3 0
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial 0 7 4
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut 2506 5294 0
102 Klozapin tab 25 mg selaput/kaplet
tablet 47 53 9
103 Kodein tab 10 mg tablet/kapsul/ 58 221 0
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/ 0 95 4
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial 156 224 0
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab
2565 9424 0
107 kombinasi : sulfametoksazol
Kotrimoksazol kombinasi tiap 5 botol 60 mL 140 286 0
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @ 74 22 0
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab 420 1222 0
113 Loratadin tab 10 mg tablet/kapsul/ 345 1000 0
114 Magnesium sulfat inj 20% kaplet
ampul/vial 0 35 2
115 Magnesium sulfat inj 40% @25 ml
ampul/vial 2 37 0
116 Metformin tab 500 mg @25 ml
tablet/kapsul/ 9223 15445 0
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial 359 78 0
118 Metilergometrin tab salut 0,125 tablet/kaplet 209 585 0
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial 978 322
121 Metoklopramid tab 10 mg tablet/kapsul/ 1046 954
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/ 1542 4961 0
125 Mikonazol krim 2% kaplet
tube 33 349 0
126 N-asetil sistein kaps 200 mg tablet/kapsul/ 9226 20407 0
127 NaCl 0,9% Larutan kaplet@500 ml
Botol 213 905 0
128 Natrium diklofenak tab 50 mg tablet salut 3727 12968 0
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/ 1377 2278 0
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial 26 34 0
131 Nistatin tab salut 500.000 UI tablet salut 92 883 0
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet 188 289 0
133 Oksimetazolin tts hidung botol @ 10 mL 3 7 3
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
135 0,050%
Oksitetrasiklin 1% Salep Mata tube 33 217 3
136 Oksitosin inj 10 UI/ml ampul/vial 221 159 0
137 Omeprazol inj 40 mg/10 ml ampul/vial 174 568 0
138 Omeprazol kaps 20 mg tablet/kapsul/ 15950 5956 0
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol 480 1070 0
140 Parasetamol tab 500 mg tablet/kapsul/ 24883 46578 0
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol 0 83 1
142 Pasta devitalisasi (non arsen) Tube 1 3 0
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube 7 3
145 Permetrin krim 5 % Tube 10 g 16 68 0
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl 4160 14540 0
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL 28 48 0
149 Povidon iodin lar 100 mg/ml Botol 300 ml 9 10 0
150 Povidon iodin lar obat kumur Botol 33 15 0
151 1%
Prednison tab 5 mg tablet/kapsul/ 2804 15196 0
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/ 188 0
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/ 5577 16299 0
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps 1300 7
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak 451 9839 0
200.000 UI
157 Ringer Laktat Larutan Botol 279 1411 0
158 Risperidon tab sal 2 mg tablet/kapsul/ 2747 3938 0
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram 28 146 0
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/ 1535 1237 0
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol 13 17 0
162 ml
Serum anti bisa ular : A.B.U. I Vial 1 6 0
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul 8 36 0
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL 32 61 0
165 Sianokobalamin (vitamin B12) ampul/vial 92 199 0
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/ 5284 10091 0
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut 2415 8422 0
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/ 190 235 0
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/ 6162 28514 0
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet 9645 31769 0
175 Vitamin C 500 mg minimal non Tablet/ 18936 19852 0
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol 9 20 1
177 Zinc sir 20 mg/5 ml botol 826 838 0
178 Zinc tab disp 20 mg tablet 9046 4744 0
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
18 332 60 100
1206 21705 19164 20000
0 0 0 0
#DIV/0! #DIV/0! #DIV/0! 50
200 3600 3600 500
4 67 10 100
997 17948 7109 10000
1414 25455 23307 25000
56 1000 705 1000
#DIV/0! #DIV/0! #DIV/0! 0
3402 61241 27607 28000
0 0 -30 0
75 1357 938 1000
2494 44899 39314 40000
149 2675 2675 2500
8 149 131 150
23 411 366 370
155 2783 2352 2500
750 13506 13506 13500
281 5065 5065 5000
17 311 -104 500
4410 79385 61577 62000
74 1325 1035 1000
107 1929 1856 2000
263 4729 3203 3200
0 0 0 0
0 7 5 5
14 244 194 200
340 6117 4105 4000
19 345 323 325
1 23 12 20
7 123 23 100
20 353 197 200
1380 24837 22109 23000
3 47 36 40
0 3 -4 10
18 324 183 200
13 225 225 100
137 2461 2461 2000
412 7419 6419 7000
51 914 914 500
212 3824 2465 2500
 7 124 114 100
0 0 0
67 1208 1208 1000
12 221 -3 200
1 20 9 10
0 5 3 3
0 0 0
60 1080 -1260
34 619 307
41 733 361
252 4534 3221
0 0 0
0 0 0
0 5 4
2 41 -2
160 2887 2576
346 6235 2890
0 0 0
18 324 239
0 7 4
1497 26943 22360
1160 20877 12765
1 23 -10
8 149 149
2 43 -42
46 820 706
0 0 0
0 0 0
398 7172 3915
501 9011 9011
0 0 0
1 9 5
36 640 476
25 452 382
190 3420 172
34 607 607
1684 30305 24818
759 13667 9601
0 0 0
0 0 0
16 296 2
1 16 6
0 0 0
1838 33091 28765
709 12757 7580
87 1571 1411
11 200 190
120 2165 1863
144 2585 2145
0 0 0
479 8619 8225
18 322 310
17 314 274
5 83 64
5 96 76
2152 38741 30547
0 5 4
1 18 18
481 8663 6157
27 477 430
20 362 304
14 244 244
20 367 211
857 15421 12856
26 468 328
0 0 0
2 36 -38
0 0 0
0 0 0
111 2000 1580
91 1636 1291
4 70 70
3 61 59
1404 25274 16051
7 128 -231
53 957 748
0 0 0
29 527 -451
87 1561 515
0 0 0
0 0 0
451 8118 6576
32 571 538
1855 33393 24167
82 1481 1268
1179 21220 17493
207 3728 2351
3 56 30
80 1445 1353
26 473 285
1 16 13
0 0 0
27 488 455
14 260 39
52 929 755
541 9746 -6204
97 1751 1271
4234 76219 51336
8 149 149
0 5 4
0 0 0
0 5 -2
6 111 95
0 0 0
1322 23793 19633
4 79 51
1 16 7
1 25 -8
1381 24866 22062
0 0 -188
0 0 0
1482 26671 21094
325 5850 5850
894 16100 15649
128 2309 2030
358 6444 3697
13 239 211
112 2024 489
2 28 15
1 10 9
3 59 51
6 100 68
18 326 234
917 16513 11229
0 0 0
766 13781 11366
21 385 195
0 0 0
2592 46659 40497
 0 0 0
0 0 0
2888 51986 42341
1805 32485 13549
2 36 27
76 1371 545
431 7763 -1283
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Pemakaian
Sisa Stok Per
Sampai
30 November
No Obat Generik Satuan November
Tahun 2022
Tahun 2022
(a)
(b)
1 Air untuk injeksi amp 25 ml ampul/vial/
botol 25 mL 30 31
2 Alopurinol tab 100 mg Tab 11606 7394
3 Alopurinol tab 300 mg tablet/kapsul/
kaplet 0 0
4 Aminofilin inj 24 mg/ml ampul/vial 10
ml 0 0
5 Aminofilin Tab 200 mg tablet/kapsul/
kaplet 0 0
6 Amitriptilin tab sal 25 mg tablet/kapsul/
kaplet 224 0
7 Amlodipin tab 10 mg tablet/kapsul/
kaplet 540 14460
8 Amlodipin tab 5 mg tablet/kapsul/
kaplet 652 3248
9 Amoksisilin sir kering 125 mg/5 ml Botol 163 241
10 Amoksisilin tab 250 mg tablet/kapsul/
kaplet 0 0
11 Amoksisilin tab 500 mg tablet/kapsul/
kaplet 47160 25054
12 Ampisilin serb inj 1000 mg/vial ampul/vial 0 0
13 Anestetik lokal gigi kombinasi : lidokain hcl
ampul/vial
2% + epinefrin 1 : 80.000 inj 2 ml 77 333
14 Antasida, kombinasi : aluminium hidroksida tablet/kapsul/
200 mg + magnesium hidroksida 200 mg kaplet
31573 43335
15 Antasida, kombinasi : aluminium hidroksida botol 60 ml
200 mg + magnesium hidroksida 200 mg
0 259
16 Antifungi salep, kombinasi : asam benzoat pot 30 g
6%+ asam salisilat 3% 0 9
17 Antihemoroid, kombinasi: bismut subgalat Suppositoria
150 mg + heksaklorofen 2,5 mg + lidokain
lidokain 10 mg+ seng oksida 120 mg + sup
ad 2 g 33 67
18 Asam asetilsalisilat (asetosal) tab 80 mg tablet/kapsul/
kaplet 130 100
19 Asam askorbat (vitamin C) tab 250 mg Tab 10000 2780
20 Asam askorbat (vitamin C) tab 50 mg tablet/kapsul/
kaplet 0 0
21 Asam folat tab 0,4 mg tablet/kapsul/
kaplet 666 949
22 Asam mefenamat kaps 500 mg tablet/kapsul/
kaplet/kaptab 20260 26047
23 Asiklovir tab 200 mg tablet/kapsul/
kaplet 40 60
24 Asiklovir tab 400 mg tablet/kapsul/
kaplet 345 874
25 Atapulgit 600 mg tablet/kapsul/
kaplet 1327 889
26 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) Ampul 20 0
27 Bahan tumpatan sementara lar, serb Botol 0 2
28 Bedak salisil serb 2% Dus/Sachet/
Plastik 17 67
29 Betahistin tab 6 mg tablet/kapsul/
kaplet 156 2374
30 Betametason krim 0,1% tube 5 gram 77 55
31 Bisakodil sup 10 mg Suppositoria 27 10
32 Bisakodil tab sal 5 mg tablet/kapsul/
kaplet 41 59
33 Deksametason inj 5 mg/ml (i.v./i.m.) ampul/vial 213 30
34 Deksametason tab 0,5 mg tablet/kapsul/
kaplet 2536 11064
35 Diazepam enema 5 mg/2,5 ml tube @ 2,5 mL
6 9
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial 3 2
37 Diazepam tab 2 mg tablet/kapsul/
kaplet 165 10
38 Difenhidramin inj 10 mg/ml (i.v./i.m.) ampul/vial 18 10
39 Digoksin tab 0,25 mg tablet/kapsul/
kaplet 0 0
40 Dimenhidrinat tab 50 mg tablet/kapsul/
kaplet 120 200
41 Domperidon susp 5 mg/5 ml botol @60 ml 0 23
42 Domperidon tab 10 mg tablet/kapsul/
kaplet 300 324
43 Epinefrin (adrenalin) inj 1 mg/ml Ampul 15 43
44 Eritromisin sir 200 mg/5 ml Botol @ 60 ml
0 5
45 Eritromisin tab 500 mg tablet/kapsul/
kaplet 0 220
46 Etanol 70% cairan 70% Botol 49 34
47 Etil klorida semprot 100 ml Botol 21 14
48 Eugenol Botol 0 0
49 Fenitoin Na inj 50 mg/ml (100 mg/ 2 mL) ampul @ 2 ml
0 0
50 Fenitoin Na kaps 100 mg Kaps 570 2040
51 Fenobarbital tab 30 mg tablet/kapsul/
kaplet 64 36
52 Fitomenadion (vitamin K 1) inj 2 mg/ml (i.m.) ampul/vial
10 180
53 Fitomenadion (vitamin K 1) tab sal 10 mg Tab sal 271 2401
54 Fitomenadion (vitamin K1) inj 10 mg/ml (i.m) tablet salut
gula/kaplet
salut gula 0 0
55 Fluoksetin kaps 10 mg tablet/kapsul/
kaplet 0 0
56 Formokresol Botol 0 0
57 Furosemid inj 10 mg/ml (i.v./i.m.) ampul/vial 0 0
58 Furosemid tab 40 mg tablet/kapsul/
kaplet 104 96
59 Garam oralit kombinasi : natrium klorida sachet
0,52 g + kalium klorida 0,30 g + trinatrium
sitrat 0,58 g + glukosa anhidrat 2,7 g
2300 5617
60 Gentamisin salep mata 0,3% Tube 8 16
61 Gentamisin tts mata 0,3% Botol 39 154
62 Glass ionomer ART (Atraumatic Restorative Botol
Treatment) lar 0 0
63 Glibenklamid tab 5 mg tablet/kapsul/
kaplet 2676 4230
64 Glimepirid tab 2 mg tablet/kapsul/
kaplet 10044 3246
65 Glukosa Larutan Infus 10% steril 500 ml Botol 0 0
66 Glukosa Larutan Infus 40% Ampul @25 ml
0 0
67 Glukosa Larutan Infus 5% steril 500 ml Botol 28 17
68 Griseofulvin (micronized) tab 125 mg tablet/kapsul/
kaplet 90 10
69 Haloperidol inj 5 mg/ml (i.m.) Vial 0 0
70 Haloperidol tab 0,5 mg tablet/kapsul/
kaplet 0 0
71 Haloperidol tab 1,5 mg tablet/kapsul/
kaplet 490 410
72 Haloperidol tab 5 mg tablet/kapsul/
kaplet 0 0
73 Haloperidol tts 2 mg/ml botol 0 0
74 Hidrogen peroksida cairan 3% Botol 7 1
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
kaplet 69 73
76 Hidrokortison krim 2,5% tube @ 5 g 31 94
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
kaplet 600 200
78 Ibuprofen sir 100 mg/5 ml botol @ 60 ml
0 0
79 Ibuprofen tab 200 mg tablet/kapsul/
kaplet 2241 5499
80 Ibuprofen tab 400 mg tablet/kapsul/
kaplet 5956 7294
81 Isoniazid tab 100 mg Tab 0 0
82 Isoniazid tab 300 mg Tab 0 0
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
kaplet 72 128
84 Kalsium glukonat inj 100 mg/ml ampul/vial 2 9
85 Kalsium hidroksida bubuk, pasta Tube 0 0
86 Kalsium laktat (kalk) tab 500 mg tablet/kapsul/
kaplet 10735 23865
87 Kaptopril tab 25 mg tablet/kaplet 6 3611
88 Karbamazepin Tab 200 mg Tablet 4880 700
89 Karbogliserin tts telinga 10 % Botol 0 0
90 Ketokonazol tab 200 mg tablet/kapsul/
kaplet 410 890
91 Klindamisin kaps 300 mg tablet/kapsul/
kaplet 280 10
92 Klonidin tab 0,15 mg tablet/kapsul/
kaplet 0 0
93 Kloramfenikol kaps 250 mg tablet/kapsul/
kaplet 260 165
94 Kloramfenikol salep mata 1% tube @ 5 gram
0 10
95 Kloramfenikol susp 125 mg/5 ml botol 60 ml 0 0
96 Kloramfenikol tetes telinga 3% Botol 26 40
97 Kloramfenikol tts mata 0,5% botol 0 0
98 Klorfeniramin tab 4 mg tablet/kapsul/
kaplet 13530 25470
99 Klorfenol kamfer mentol (CHKM) Botol 0 0
100 Klorpromazin inj 25 mg/ml (i.m.) ampul/vial 0 0
101 Klorpromazin tab sal 100 mg tablet salut
selaput/kaplet
salut selaput
2565 2684
102 Klozapin tab 25 mg tablet 435 565
103 Kodein tab 10 mg tablet/kapsul/
kaplet 0 0
104 Kombinasi : ergotamin 1 mg+ kafein 50 mg tablet/kapsul/
kaplet 100 0
105 Kombinasi: Ipratropium bromida 0,5 mg + Ampul/vial
Salbutamol 2,5 mg, cairan ih 0 0
106 Kotrimoksazol (dewasa) kombinasi : tab/kaptab
sulfametoksazol 400 mg+ trimetoprim 80 mg
170 1933
107 Kotrimoksazol kombinasi tiap 5 ml botol 60 mL
suspensi : sulfametoksazol 200 mg +
trimetoprim 40 mg 76 84
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
0 0
109 Larutan mengandung Elektrolit (Na 130 Softbag @
mEq, K 4 mEq, Cl 109 mEq, Ca 3 mEq, 500 ml
Asetat 28 mEq) Ringer Asetat 0 0
110 Lidokain inj 2% (infiltr/p.v.) ampul/vial 500 0
111 Lidokain spray oral 10% botol 0 0
112 Loperamid tab 2 mg Tab 120 90
113 Loratadin tab 10 mg tablet/kapsul/
kaplet 4889 1276
114 Magnesium sulfat inj 20% ampul/vial
@25 ml 0 43
115 Magnesium sulfat inj 40% ampul/vial
@25 ml 0 41
116 Metformin tab 500 mg tablet/kapsul/
kaplet 5020 2410
117 Metilergometrin inj 0,2 mg/ml ampul/vial 60 2115
118 Metilergometrin tab salut 0,125 mg tablet/kaplet
salut selaput 1101 529
119 Metilprednisolon inj 125 mg/2 ml ampul/vial 0 0
120 Metoklopramid inj 5 mg/ml ampul/vial 0 0
121 Metoklopramid tab 10 mg tablet/kapsul/
kaplet 200 600
122 Metronidazol lar inf 5 mg/ml botol 0 0
123 Metronidazol susp 125 mg/5 ml Botol @ 60 ml
0 0
124 Metronidazol tab 500 mg tablet/kapsul/
kaplet 1701 1438
125 Mikonazol krim 2% tube 43 77
126 N-asetil sistein kaps 200 mg tablet/kapsul/
kaplet 10316 19244
127 NaCl 0,9% Larutan Botol @500 ml
32 9
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
salut enterik 1550 6270
129 Nifedipin kaps 10 mg tablet/kapsul/
kaplet 10 90
130 Nistatin susp 100.000 UI/ml botol/vial 0 0
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
salut gula 8 92
132 Nistatin tab vaginal 100.000 UI tablet/kaplet 76 85
133 Oksimetazolin tts hidung 0,025% botol @ 10 mL
0 0
134 Oksimetazolin tts hidung 0,050% botol @ 10 mL
0 0
135 Oksitetrasiklin 1% Salep Mata tube 0 142
136 Oksitosin inj 10 UI/ml ampul/vial 0 200
137 Omeprazol inj 40 mg/10 ml ampul/vial 0 0
138 Omeprazol kaps 20 mg tablet/kapsul/
kaplet 2171 2629
139 Parasetamol sir 120 mg/5 ml botol @ 60 mL
196 261
140 Parasetamol tab 500 mg tablet/kapsul/
kaplet 23037 47363
141 Parasetamol tts 60 mg/0,6 ml botol @ 15 mL
0 25
142 Pasta devitalisasi (non arsen) Tube 0 1
143 Pasta pengisi saluran akar (pasta) Tube 0 0
144 Perak sulfadiazin krim 1% Tube 5 8
145 Permetrin krim 5 % Tube 10 g 10 46
146 Pirantel pamoat tab scored 125 mg tablet/kapsul/
kaplet 36 0
147 Piridoksin (vitamin B6) tab 10 mg tab/kap/kapl 242 7383
148 Povidon iodin lar 100 mg/ml botol 30 mL 2 26
149 Povidon iodin lar 100 mg/ml Botol 300 ml 8 2
150 Povidon iodin lar obat kumur 1% Botol 14 11
151 Prednison tab 5 mg tablet/kapsul/
kaplet 2353 3298
152 Propiltiourasil tab 100 mg tablet/kapsul/
kaplet 90 0
153 Propranolol tab 10 mg tablet/kapsul/
kaplet 0 0
154 Ranitidin tab 150 mg tablet/kapsul/
kaplet 2429 3441
155 Retinol (vitamin A) kaps lunak 100.000 UI kaps lunak 0 450
156 Retinol (vitamin A) kaps lunak 200.000 UI kaps lunak 0 6000
157 Ringer Laktat Larutan Botol 18 82
158 Risperidon tab sal 2 mg tablet/kapsul/
kaplet 3530 9570
159 Salep 2-4, kombinasi : asam salisilat 2 %+ pot 30 gram
belerang endap 4 % 5 93
160 Sefadroksil kaps/tab 500 mg tablet/kapsul/
kaplet 1500 50
161 Sefadroksil sir kering 125 mg/5 ml botol @ 60 mL
0 0
162 Serum anti bisa ular : A.B.U. I (khusus ular Vial
dari luar Papua) inj (i.m./i.v.) 2 0
163 Serum antitetanus (A.T.S) inj 1500 UI/amp Ampul
(i.m.) 0 0
164 Setirizin sir 5 mg/5 ml. botol @ 60 mL
3 5
165 Sianokobalamin (vitamin B12) inj 500 ampul/vial
mcg/ml 90 90
166 Simvastatin tab sal 10 mg tablet/kapsul/
kaplet/tablet
salut
selaput/kaplet
salut selaput
21725 5715
167 Simvastatin tab sal 20 mg tablet/kapsul/
kaplet/tablet
salut
selaput/kaplet
salut selaput
0 0
168 Siprofloksasin tab scored 500 mg tablet salut
selaput/kaplet
salut selaput
4086 1332
169 Spironolakton tab 25 mg tablet/kapsul/
kaplet 0 0
170 Tetrakain tts mata 0,5% Botol 0 0
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet 10000 21544
172 Urea krim 10 % Tube/pot 0 0
173 Valproat sir 250 mg/5 ml botol @ 120
ml 3 0
174 Vitamin B kompleks tablet 4809 28180
175 Vitamin C 500 mg minimal non acidic 250 Tablet/
mg kapsul/kaplet/
tab sal
selaput/kaplet
sal selaput/tab
sal gula/kaplet
sal gula

0 17762
176 Zinc drops 10 mg/ml Botol 0 0
177 Zinc sir 20 mg/5 ml botol 588 461
178 Zinc tab disp 20 mg tablet
dispersible 5700 8219
 Pemakaian
Jumlah Bulan Jumlah Rencana Rencana Keterangan
Rata2
Kekosongan Kebutuhan Kebutuhan Pengadaan
Per Bulan
Obat Tahun 2023 Tahun 2023 Tahun 2023
(d) = (b)/(11-
(c) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
(c))

3 51 21 30
672 12099 493 2000

0 0 0 0

0 0 0

0 0 0

0 0 -224 0

1315 23662 23122 20000

295 5315 4663 10000

22 394 231 300

0 0 0 0

2278 40997 -6163 10000

0 0 0 0

30 545 468 500

3940 70912 39339 50000

24 424 424 500

1 15 15 0

6 110 77 100

9 164 34 100
253 4549 -5451 0

0 0 0 0

86 1553 887 1000

2368 42622 22362 50000

5 98 58 100

79 1430 1085 2000

81 1455 128 200

0 0 -20 0
0 3 3 3
 6 110 93 100

216 3885 3729 4000

5 90 13 25
1 16 -11 10

5 97 56 100
3 49 -164 50

1006 18105 15569 20000

1 15 9 10
0 3 0 5

1 16 -149 100
1 16 -2 20

0 0 0 0

18 327 207 200

2 38 38 50

29 530 230 300

4 70 55 50

0 8 8 10

20 360 360 500

3 56 7 10
1 23 2 5
0 0 0 0

0 0 0 0
185 3338 2768 5000

3 59 -5 100

16 295 285 300

2 267 4802 4531 5000

0 0 0 0

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

9 157 53 100

511 9191 6891 0

1 26 18 25
2 17 308 269 300

0 0 0 0
 385 6922 4246 5000

1 325 5843 -4201 1000

0 0 0 0

0 0 0 0
2 28 0 0

1 16 -74 0
0 0 0 5

0 0 0 0

37 671 181 300

0 0 0 0
0 0 0 0
0 2 -5 0

7 119 50 100
9 154 123 150

18 327 -273 500

0 0 0 20

500 8998 6757 10000

663 11936 5980 10000

0 0 0 0
0 0 0 0

12 209 137 200

1 15 13 15
0 0 0 0

2170 39052 28317 30000

328 5909 5903 10000
64 1145 -3735 0
0 0 0 0

81 1456 1046 2000

1 16 -264 0

0 0 0 0

15 270 10 100

1 16 16 20
0 0 0 0
4 65 39 50
0 0 0 0

2315 41678 28148 30000

0 0 0 0
 0 0 0 0

2 298 5368 2803 5000

51 925 490 500

0 0 0 0

0 0 -100 0

0 0 0 0

176 3163 2993 5000

8 137 61 50

0 0 0 0

0 0 0 0
0 0 -500 0
0 0 0 3
8 147 27 100

3 160 2871 -2018 1000

4 70 70 100

4 67 67 100

219 3944 -1076 0

192 3461 3401 0

48 866 -235 200

0 0 0 0
0 0 0 0

55 982 782 1000

0 0 0 0

0 0 0 0

131 2353 652 1000

7 126 83 100

1749 31490 21174 30000

1 15 -17 0

570 10260 8710 20000

8 147 137 200

0 0 0 10
 8 151 143 200
8 139 63 100

0 0 0 0

0 0 0 0
13 232 232 200
18 327 327 400
0 0 0 0

239 4302 2131 3000

24 427 231 300

4306 77503 54466 60000

2 41 41 50
0 2 2 3
0 0 0 0
1 13 8 10
4 75 65 100

0 0 -36 0
671 12081 11839 15000
2 43 41 50
0 3 -5 0
1 18 4 0

300 5397 3044 5000

0 0 -90 0

0 0 0 0

313 5631 3202 5000

41 736 736 800
545 9818 9818 10000
7 134 116 200

870 15660 12130 15000

2 10 186 181 200

5 82 -1418 0

0 0 0 0

0 0 -2 0

0 0 0 2

0 8 5 10

8 147 57 100
 520 9352 -12373 0

0 0 0 0

121 2180 -1906 0

0 0 0 300
0 0 0 0

1959 35254 25254 30000

0 0 0 0

0 0 -3 0
2562 46113 41304 50000

3 2220 39965 39965 50000

0 0 0 0
42 754 166 0

747 13449 7749 0

 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
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0 0 0
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0 0 0
0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
0 0 0
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0 0 0
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0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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0 0 0
0 0 0
0 0 0
 Tahun 2022 Tahun 2022 Obat
No Obat Generik Satuan (a) (b) (c)
1 Air untuk injeksi amp 25 ml ampul/vial/
2 Alopurinol tab 100 mg botol 25 mL
Tab
3 Alopurinol tab 300 mg tablet/kapsul/
4 Aminofilin inj 24 mg/ml kaplet
ampul/vial 10
5 Aminofilin Tab 200 mg ml
tablet/kapsul/
6 Amitriptilin tab sal 25 mg kaplet
tablet/kapsul/
7 Amlodipin tab 10 mg kaplet
tablet/kapsul/
8 Amlodipin tab 5 mg kaplet
tablet/kapsul/
9 kaplet
Amoksisilin sir kering 125 mg/5 Botol
10 ml
Amoksisilin tab 250 mg tablet/kapsul/
11 Amoksisilin tab 500 mg kaplet
tablet/kapsul/
12 kaplet
Ampisilin serb inj 1000 mg/vial ampul/vial
13 Anestetik lokal gigi kombinasi : ampul/vial
14 lidokain
Antasida,hclkombinasi
2% + epinefrin
: 1 : tablet/kapsul/

15 aluminium hidroksida: 200 mg + botol

Antasida, kombinasi kaplet60 ml

16 aluminium hidroksida
Antifungi salep, 200 mg
kombinasi : + pot 30 g
17 asam benzoat kombinasi:
Antihemoroid, 6%+ asam Suppositoria
18 bismut subgalat 150(asetosal)
Asam asetilsalisilat mg + tablet/kapsul/
19 tab 80 mg kaplet
Asam askorbat (vitamin C) tab Tab
20 250
Asam mgaskorbat (vitamin C) tab tablet/kapsul/
21 50 mg folat tab 0,4 mg
Asam kaplet
tablet/kapsul/
22 Asam mefenamat kaps 500 mg kaplet
tablet/kapsul/
23 Asiklovir tab 200 mg kaplet/kaptab
tablet/kapsul/
24 Asiklovir tab 400 mg kaplet
tablet/kapsul/
25 Atapulgit 600 mg kaplet
tablet/kapsul/
26 Atropin inj 0,25 mg/ml kaplet
Ampul
27 (i.m./i.v./s.k)
Bahan tumpatan sementara Botol
28 lar,
Bedakserbsalisil serb 2% Dus/Sachet/
29 Betahistin tab 6 mg Plastik
tablet/kapsul/
30 Betametason krim 0,1% kaplet5 gram
tube
31 Bisakodil sup 10 mg Suppositoria
32 Bisakodil tab sal 5 mg tablet/kapsul/
33 Deksametason inj 5 mg/ml kaplet
ampul/vial
34 (i.v./i.m.)
Deksametason tab 0,5 mg tablet/kapsul/
35 kaplet@ 2,5 mL
Diazepam enema 5 mg/2,5 ml tube
36 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
37 Diazepam tab 2 mg tablet/kapsul/
38 Difenhidramin inj 10 mg/ml kaplet
ampul/vial
39 (i.v./i.m.)
Digoksin tab 0,25 mg tablet/kapsul/
40 Dimenhidrinat tab 50 mg kaplet
tablet/kapsul/
41 Domperidon susp 5 mg/5 ml kaplet@60 ml
botol
42 Domperidon tab 10 mg tablet/kapsul/
kaplet
43 Epinefrin (adrenalin) inj 1 Ampul
44 mg/ml
Eritromisin sir 200 mg/5 ml Botol @ 60 ml
45 Eritromisin tab 500 mg tablet/kapsul/
46 Etanol 70% cairan 70% kaplet
Botol
47 Etil klorida semprot 100 ml Botol
48 Eugenol Botol
49 Fenitoin Na inj 50 mg/ml (100 ampul @ 2 ml
50 mg/ 2 mL)
Fenitoin Na kaps 100 mg Kaps
51 Fenobarbital tab 30 mg tablet/kapsul/
52 kaplet
Fitomenadion (vitamin K 1) inj ampul/vial
53 2 mg/ml (i.m.) (vitamin K 1) tab Tab sal
Fitomenadion
54 sal 10 mg
Fitomenadion (vitamin K1) inj tablet salut
55 10 mg/ml (i.m)
Fluoksetin kaps 10 mg gula/kaplet
tablet/kapsul/
56 Formokresol kaplet
Botol
57 Furosemid inj 10 mg/ml ampul/vial
58 (i.v./i.m.)
Furosemid tab 40 mg tablet/kapsul/
59 Garam oralit kombinasi : kaplet
sachet
60 natrium klorida
Gentamisin 0,52
salep g +0,3%
mata kalium Tube

61 Gentamisin tts mata 0,3% Botol

62 Glass ionomer ART Botol
63 (Atraumatic
GlibenklamidRestorative
tab 5 mg tablet/kapsul/
64 Glimepirid tab 2 mg kaplet
tablet/kapsul/
65 Glukosa Larutan Infus 10% kaplet
Botol
66 steril
Glukosa500Larutan
ml Infus 40% Ampul @25 ml
67 Glukosa Larutan Infus 5% Botol
68 steril 500 ml (micronized) tab
Griseofulvin tablet/kapsul/
69 125 mg
Haloperidol inj 5 mg/ml (i.m.) kaplet
Vial
70 Haloperidol tab 0,5 mg tablet/kapsul/
71 Haloperidol tab 1,5 mg kaplet
tablet/kapsul/
72 Haloperidol tab 5 mg kaplet
tablet/kapsul/
73 Haloperidol tts 2 mg/ml kaplet
botol
74 Hidrogen peroksida cairan 3% Botol
75 Hidroklorotiazid tab 25 mg tablet/kapsul/
76 Hidrokortison krim 2,5% kaplet@ 5 g
tube
77 Hiosina butilbromida tab 10 mg tablet/kapsul/
78 Ibuprofen sir 100 mg/5 ml kaplet@ 60 ml
botol
79 Ibuprofen tab 200 mg tablet/kapsul/
80 Ibuprofen tab 400 mg kaplet
tablet/kapsul/
81 Isoniazid tab 100 mg kaplet
Tab
82 Isoniazid tab 300 mg Tab
83 Isosorbid dinitrat tab 5 mg tablet/kapsul/
84 kaplet
Kalsium glukonat inj 100 mg/ml ampul/vial
85 Kalsium hidroksida bubuk, Tube
pasta
86 Kalsium laktat (kalk) tab 500 tablet/kapsul/
87 mg
Kaptopril tab 25 mg kaplet
tablet/kaplet
88 Karbamazepin Tab 200 mg Tablet
89 Karbogliserin tts telinga 10 % Botol
90 Ketokonazol tab 200 mg tablet/kapsul/
91 Klindamisin kaps 300 mg kaplet
tablet/kapsul/
92 Klonidin tab 0,15 mg kaplet
tablet/kapsul/
93 Kloramfenikol kaps 250 mg kaplet
tablet/kapsul/
94 Kloramfenikol salep mata 1% kaplet@ 5 gram
tube
95 Kloramfenikol susp 125 mg/5 botol 60 ml
96 ml
Kloramfenikol tetes telinga 3% Botol
97 Kloramfenikol tts mata 0,5% botol
98 Klorfeniramin tab 4 mg tablet/kapsul/
99 Klorfenol kamfer mentol kaplet
Botol
100 (CHKM)
Klorpromazin inj 25 mg/ml ampul/vial
101 (i.m.)
Klorpromazin tab sal 100 mg tablet salut
102 Klozapin tab 25 mg selaput/kaplet
tablet
103 Kodein tab 10 mg tablet/kapsul/
104 Kombinasi : ergotamin 1 mg+ kaplet
tablet/kapsul/
105 kafein 50 mg
Kombinasi: Ipratropium kaplet
Ampul/vial
106 bromida 0,5 mg(dewasa)
Kotrimoksazol + Salbutamol tab/kaptab

107 kombinasi : sulfametoksazol

Kotrimoksazol kombinasi tiap 5 botol 60 mL
ml suspensi : sulfametoksazol
108 Laktulosa sir 3,335 g/5 ml botol @ 60 mL
109 Larutan mengandung Elektrolit Softbag @
110 (Na 130 mEq,
Lidokain inj 2%K(infiltr/p.v.)
4 mEq, Cl 109 ampul/vial
500 ml

111 Lidokain spray oral 10% botol

112 Loperamid tab 2 mg Tab
113 Loratadin tab 10 mg tablet/kapsul/
114 Magnesium sulfat inj 20% kaplet
ampul/vial
115 Magnesium sulfat inj 40% @25 ml
ampul/vial
116 Metformin tab 500 mg @25 ml
tablet/kapsul/
117 Metilergometrin inj 0,2 mg/ml kaplet
ampul/vial
118 Metilergometrin tab salut 0,125 tablet/kaplet
119 mg salut selaput
Metilprednisolon inj 125 mg/2 ampul/vial
120 ml
Metoklopramid inj 5 mg/ml ampul/vial
121 Metoklopramid tab 10 mg tablet/kapsul/
122 Metronidazol lar inf 5 mg/ml kaplet
botol
123 Metronidazol susp 125 mg/5 Botol @ 60 ml
124 ml
Metronidazol tab 500 mg tablet/kapsul/
125 Mikonazol krim 2% kaplet
tube
126 N-asetil sistein kaps 200 mg tablet/kapsul/
127 NaCl 0,9% Larutan kaplet@500 ml
Botol
128 Natrium diklofenak tab 50 mg tablet salut
enterik/kaplet
129 Nifedipin kaps 10 mg tablet/kapsul/
130 Nistatin susp 100.000 UI/ml kaplet
botol/vial
131 Nistatin tab salut 500.000 UI tablet salut
gula/kaplet
132 Nistatin tab vaginal 100.000 UI tablet/kaplet
133 Oksimetazolin tts hidung botol @ 10 mL
134 0,025%
Oksimetazolin tts hidung botol @ 10 mL
0,050%
135 Oksitetrasiklin 1% Salep Mata tube
136 Oksitosin inj 10 UI/ml ampul/vial
137 Omeprazol inj 40 mg/10 ml ampul/vial
138 Omeprazol kaps 20 mg tablet/kapsul/
139 Parasetamol sir 120 mg/5 ml kaplet@ 60 mL
botol
140 Parasetamol tab 500 mg tablet/kapsul/
141 Parasetamol tts 60 mg/0,6 ml kaplet@ 15 mL
botol
142 Pasta devitalisasi (non arsen) Tube
143 Pasta pengisi saluran akar Tube
144 (pasta)
Perak sulfadiazin krim 1% Tube
145 Permetrin krim 5 % Tube 10 g
146 Pirantel pamoat tab scored tablet/kapsul/
147 125 mg (vitamin B6) tab 10
Piridoksin kaplet
tab/kap/kapl
148 mg
Povidon iodin lar 100 mg/ml botol 30 mL
149 Povidon iodin lar 100 mg/ml Botol 300 ml
150 Povidon iodin lar obat kumur Botol
151 1%
Prednison tab 5 mg tablet/kapsul/
152 Propiltiourasil tab 100 mg kaplet
tablet/kapsul/
153 Propranolol tab 10 mg kaplet
tablet/kapsul/
154 Ranitidin tab 150 mg kaplet
tablet/kapsul/
kapletlunak
155 Retinol (vitamin A) kaps lunak kaps
156 100.000 UI
Retinol (vitamin A) kaps lunak kaps lunak
200.000 UI
157 Ringer Laktat Larutan Botol
158 Risperidon tab sal 2 mg tablet/kapsul/
159 Salep 2-4, kombinasi : asam kaplet
pot 30 gram
160 salisilat 2 %+
Sefadroksil belerang
kaps/tab endap
500 mg tablet/kapsul/
kaplet@ 60 mL
161 Sefadroksil sir kering 125 mg/5 botol
162 ml
Serum anti bisa ular : A.B.U. I Vial
163 (khusus ular dari luar
Serum antitetanus Papua)
(A.T.S) inj Ampul
164 1500 UI/amp
Setirizin (i.m.) ml.
sir 5 mg/5 botol @ 60 mL
165 Sianokobalamin (vitamin B12) ampul/vial
166 inj 500 mcg/ml
Simvastatin tab sal 10 mg tablet/kapsul/
167 Simvastatin tab sal 20 mg kaplet/tablet
tablet/kapsul/
168 Siprofloksasin tab scored 500 kaplet/tablet
tablet salut
169 mg
Spironolakton tab 25 mg selaput/kaplet
tablet/kapsul/
170 Tetrakain tts mata 0,5% kaplet
Botol
171 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/
kaplet
172 Urea krim 10 % Tube/pot
173 Valproat sir 250 mg/5 ml botol @ 120
174 Vitamin B kompleks ml
tablet
175 Vitamin C 500 mg minimal non Tablet/
176 acidic 250 mg
Zinc drops 10 mg/ml kapsul/kaplet/
Botol
177 Zinc sir 20 mg/5 ml botol
178 Zinc tab disp 20 mg tablet
dispersible
(d) = (b)/(11- Tahun 2023 Tahun 2023 Tahun 2023
(c)) (e) = (d) x 18 (f) = (e) - (a) (g) (h)
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