Judul
Daftar Isi.....................................................................................................................................2
Daftar Obat.................................................................................................................................2
Antimikrobial (Antibiotika, Antiviral, Antifungi, Antiamuba, Antelmintika)..........................3
Antipiretika, Analgetika, Antiinflamasi, Relaksan Otot..........................................................4
Antiemetika, Antivertigo........................................................................................................5
Obat-obat Saluran Pencernaan, Antidiare.............................................................................5
Antialergi, antihistamin..........................................................................................................5
Obat-obat Saluran Pernafasan, Mukolitik, Antitusif, Ekspektoran, Flu, Asma Bronkial........5
Antipirai..................................................................................................................................7
HiperTiroid..............................................................................................................................7
Antikolesterol, hiperlipidemia................................................................................................7
Vitamin, Suplemen Suportif, bahan tambahan obat.............................................................7
Antihipertensi, obat-obat cardiovascular, diuretika..............................................................8
Antidiabetik Oral.....................................................................................................................8
Obat Pemakaian Luar, Salep-salep Kulit,................................................................................8
Sediaan Steril Mata................................................................................................................9
Sediaan Telinga.....................................................................................................................10
Obat-obat Parenteral...........................................................................................................10
Obat-obat KB dan Alat Kontrasepsi......................................................................................10
Alat kesehatan dan BMHP....................................................................................................11
2
ForNas (Tk
Nama Obat / Maksimal Peresepan pada No
N 1)
Generic / Sediaan / pasien n
o Ya Tid
Kekuatan Forn
ak as
Antimikrobial (Antibiotika, Antiviral, Antifungi,
Antiamuba, Antelmintika)
1 acyclovir 200 mg +
40tablet/kunjungan
2 acyclovir 400 mg +
50tablet/kunjungan
3 Favipiravir +
10 tablet/kunjungan
4 albendazole 400mg +
3tablet/kunjungan
5 amoxicillin 500 mg +
15tablet/kunjungan
6 Ampicillin 500 mg +
10 tablet/kunjungan
7 Azithromycin 500mg +
3tablet/kunjungan
8 Cefadroxil 500mg +
30 kapsul/kunjungan
9 cefixime 100 mg +
10kapsul/kunjungan
10 cefixime 200 mg +
10kapsul/kunjungan
11 ciprofloxacin 500 mg +
10kapsul/kunjungan
1 clindamicin 150 mg +
10kapsul/kunjungan
2
1 clindamicin 300 mg +
10kapsul/kunjungan
3
1 cotrimoxazole 480mg +
10tablet/kunjungan
4
1 doxycycline 100 mg +
15tablet/kunjungan
5
1 erithromycin 500 mg +
4tablet/kunjungan
6
1 fg troches +
10tablet/kunjungan
7 (Fradiomycin,
gramicidin)
1 Levoflofaxin 500 mg +
Maksimal 10 hari
8
1 Levofloxacin 750 mg +
Maksimal 10 hari
9
2
Primadex tablet 4 tab perhari selama 10 hari +
0
2 Thyamphenicol +
10 tablet/kunjungan
1
2 Etambutol +
Digunakan pada pengobatan TB
1
tahap awal. Kategori 1: 1 tab/15
2 Pirazinamid +
kgBB, maks selama 2 bulan
2
pertama. Kategori 2: 1 tab/15
2 Isoniazid kgBB, maks selama 3 bulan +
3 pertama.
2 Rifampisin 450 mg +
4
2 ketoconazole 200 mg +
10tablet/kunjungan
5
2 metronidazole 500 mg +
10tablet/kunjungan
6
2 sirup amoxicillin sirup +
1botol/kunjungan
7 /etamox syr 125mg/5ml
2 sirup cefadroxil/lostacef +
1botol/kunjungan
8 125mg/5ml
2 drops +
9 nistatin100.000iu/
ml 1botol/kunjungan
(cazetin)
3 pirantel pamoat 250 mg +
2 tablet dalam 1 kali kunjungan
0
3 Pirantel pamoat syrup +
1 botol dalam 1 kali kunjungan
1
6 Loperamid 2mg +
4tablet/kunjungan
(tasdiar)
7 Omeprazole 20mg +
10 tablet/kunjungan
8 Pantoprazol +
10 tablet/ kunjungan
9 Ranitidin 150mg +
10 tablet/kunjungan
1 sirup antasida +
1botol/kunjungan
0
1 Sucralfat syrup +
1 botol/ kunjungan
1
1 Hyoscine butylbromida +
10 tablet/kunjungan
2
1 Ardium 500 mg +
10 tablet/ kunjungan
3
Antialergi, antihistamin
1 Cetirizin 10mg +
6tablet/kunjungan
2 Ctm 4mg +
10tablet/kunjungan
3 Loratadin 10mg +
6tablet/kunjungan
4 sirup cetirizin 5mg/5ml +
1botol/hari
(lerzin/trisela)
Obat-obat Saluran Pernafasan, Mukolitik, Antitusif, Ekspektoran, Flu, Asma Bronkial
1 alpara/brochifar +
6tablet/kunjungan
(pct, dmp, ppa,
ctm)
2 ambroxol (broxal) 30 +
10tablet/kunjungan
mg
3 Degirol +
6tablet/kunjungan
4 Demacolin (PCT, +
6tablet/kunjungan
Pseudoefedrin, ctm)
5 (LASA) Bromifar +
6tablet/kunjungan
6 (LASA) Bromifar Plus +
6tablet/kunjungan
7 flutrop / librofed/ +
valved 6tablet/kunjungan
(Tripolidin,
pseudoefedrin)
8 GG tablet untuk PUYER +
6tablet/kunjungan
(guaifenesin 100mg)
9 Guaifenesin GG tablet +
10tablet/kunjungan
strip 100mg
1 (LASA) grantusif (dmp, +
6tablet/kunjungan
0 gg, difenhi)
1 inhalasi fluticasone
1 propionat 1ampul/kunjungan +
0.5mg/2ml
(flixotide/
hexotide)
1 inhalasi salbutamol +
1ampul/kunjungan
2 2,5mg/amp (ventolin)
1 intunal-f +
6tablet/kunjungan
3 (pct,ppa,dmp,gg,ctm)
1 (LASA) salbutamol 2 +
10tablet/kunjungan
4 mg
1 (LASA) salbutamol 4 +
10tablet/kunjungan
5 mg
1 sirup ambroxol +
1botol/kunjungan
6 15mg/5ml
1 sirup +
7 paracetin/coparce
1botol/kunjungan
tin syr (pct, gg,
efedrin,
ctm)
1 sirup dextral (Dmp, +
1botol/kunjungan
8 GG,
Ppa, ctm)
1 sirup obh +
1botol/kunjungan
9 (itrasal/berlico)
2 sirup salbutamol +
1botol/kunjungan
0 2mg/5ml
2 sirup uni baby +
1botol/kunjungan
1 cough/pacdin
2 N-asetil systein +
10 kapsul/ kunjungan
2
Antipirai
1 (LASA) allopurinol +
10tablet/kunjungan
100mg
2 (LASA) allopurinol +
10tablet/kunjungan
300mg
3 Colcichin +
10 tablet/ kunjungan
Obat Kelenjar
1 euthyrox 100 mcg 30 tablet/ 30 hari +
Antikolesterol, hiperlipidemia
1 fenofibrate 300 mg Pasien tertentu, maks. +
6tab/kunjungan
2 Gemfibrozil 300mg +
6kapsul/kunjungan
3 simvastatin 10 mg +
10tablet/kunjungan
4 Atorvastatin 20 mg
15 tablet/ 15 hari
4 Bisoprolol 5 mg
5 Nifedipin
6 Aspilet 80mg +
10hari terapi
7 (LASA) captopril 12,5 +
14hari terapi
mg
8 (LASA) captopril 25 mg +
14hari terapi
(farmoten)
9 Candesartan
1 clopidogrel 75 mg +
7hari terapi
0
1 diltiazem 30 mg +
7hari terapi
1
1 furosemid 40 mg +
7hari terapi
2
1 Isosorbid dinitrat +
5hari terapi
3 5mg /
isdn
1 (LASA) nifedipine 10 +
14hari terapi
4 mg
1 Amiodaron
5
1 Dobutamin HCl
6
Antidiabetik Oral
1 (LASA) glibenclamid 5 +
14hari terapi
mg
2 (LASA) glimepiride 1 +
14hari terapi
mg
3 (LASA) glimepiride 2mg +
14hari terapi
4 Metformin 500mg +
14hari terapi
5 Insulin lantos
6 Insulin noporapid
Anti Fibrinolitik
1 Asam tranexamat
2 Vitamin k
3 Adrome
Antitrombotik
1 Aspirin 80 mg
1 Dopamin
2 Citicolin
3 Haloperidol
4 Amitripillin
5 chlorpromazin
1 Alprazolam
2 Diazepam
3 Codifront +
20 tablet/minggu
4 Stesolid 5 mg
5 Stesolid 10 mg
6 salep 24 +
1pot (10g)
7 salep acyclovir 5% +
10gram(2tube)/kunjungan
8 salep betametason +
5gram/kunjungan
0.1%
9 salep bioplacenton +
Pasien umum dan tindakan
1 salep gentamisin 0.1% +
5gram/kunjungan
0
1 salep hidrokortison +
5gram/kunjungan
1 2,5%
1 salep ketoconazole 2% +
5gram/kunjungan
2
1 salep megatic (na- +
5gram/kunjungan
3 diklofenak 1%)
1 salep miconazole 2% +
5gram/kunjungan
4
1 salep scabimite kecil +
Pasien umum
5 (permetrin 5%) (10g)
1 salep synalten +
1 tube/kunjungan
6 (fluocinolon,gentamici
n)
1 Aloclair gel
7
1 Benzolac gel
8
1 Bioplasenton gel
9
2 Bufacomb cream
0
2 Burnazin cream
1
2 Caladin lotion
2
2 Counterpain
3
2 Derma pro
4
2 Dermacept RX
5
2 Dermatix cream
6
2 Desolex cream
7
2 Desolex-N cream
8
2 Erymed gel
9
3 Glikoderm clarify FC
1 gel
3 Glikoderm repair
3 calming
3 Heliatech sunscreen
5
3 Heparin gel
6
3 Hot in DCl
7
3 Hyaluderm
8
3 Intrasit gel
9
4 Kloderma cream
0
4 Kloderma salep
1
4 Ketomed 60 ml
2
4 Lanakeloid-E
3
4 Laroche posay
4 impropation
4 Lespain cream
6
4 Loreal paris 30 ml
7
4 Medi-klin TR
9
5 Miconazol cream
0
5 Mometason
1
5 Niacef cream
2
5 Oviskin N
3
5 Parasol SPF 33
4
5 Peditox
5
5 Pirotop cream
6
5 Refaquin 15 gram
7 cream
5 Tekasol 1% ointmen
8
5 Topicare bodywash
9
6 Topicare diaper
0 cream
6 Topicare sooting
1
6 Topicare + ceramid
2
6 Ultrasilin
3
6 Vitacid 0,025
4
6 Vitacid 0,05
4
6 Vitacod 0,1
5
6 Etil klorid +
Untuk tindakan
6
Maks 15menit/kunjungan,
6 Oksigen +
7 atau
sesuai kebutuhan
6 Perhidrol 3% +
Hanya untuk tindakan
8
6 Povidon Iodin +
Hanya untuk tindakan
9
7 Etanol 70% +
Hanya untuk tindakan
0
7 Framisetin sulfat tulle +
Untuk Tindakan
1 1%
Sediaan TELINGA
1 (LASA) tetes telinga +
1
erlamycetine 10 ml 1%
2 tetes telinga forumen +
Hanya untuk tindakan
(Na Dokusat 5mg/ml) (UMUM)
3 Ottopain
4 Otolin
Obat-obat Parenteral
1 Aminophilin 240 +
Pasien emergency
mg/ampul
2 MgSO4 20% +
Pasien emergency
3 (LASA) injeksi +
ceftriaxone powder 1hari terapi
1g
/vial
4 Injeksi Cefotaxim 1 hari terapi
5 (LASA) injeksi +
1ampul/kunjungan
dexamethasone
5mg/ml
6 Injeksi difenhidramin +
2cc/kunjungan
10mg/ml (sidiadryl)
7 injeksi epinefrin +
Pasien emergency
8 Injeksi norepinefrin 1
Pasien emergency
mg/ml
9 injeksi ketorolac +
1ampul/kunjungan
30mg/ml
1 injeksi lidocain +
1ampul/kunjungan
0 20mg/ml
1 injeksi ondansetron +
1ampul/kunjungan
1 2mg/ml
1 injeksi ranitidin +
1ampul/kunjungan
2 25mg/ml
1 Injeksi Lansoprazol 30
3 mg/ml
Injeksi omeprazol
1 Injeksi Furosemid 20
4 mg/ampul
1 Injeksi neurosanbe
5
1 nacl 500ml +
Sesuai kebutuhan
6
1 ringer laktat +
Sesuai kebutuhan
7
1 Asering
8
1 D10
9
2 D5
0
2 Futrolit
1
2 Hidromal
2
2 KAEN 3B
3
2 Manitol
4
2 Dextrose 40%
5
2 Vaksin Rabies
6
2 Vaksin Tetanus
7
1 Microlax
2 Parasetamol 125 mg
5 supositoria superhoid +
2 suppo/kunjungan (ACC
suppo (znO, benzokain, GENERIK)
alukol)
6 Haemocain
SEDIAAN INHALER
4 Oxycan
6 Bisturi no 15
7 Folley catheter no 16
8 Folley catheter no 18
9 Jarum jahit no 15
1 Wing Needle
0
1 Sarung tangan steril
1
1 Sarung tangan non
2 steril
1 Infus set anak
3
1 Insus set dewasa
4
1 Jarum no 23
5
1 Jarum no 24
6
1 Jarum no 27
7
1 Masker nebu anak
8
1 Masker nebu dewasa
9
2 Masker
0
2 Kasa steril 16x16
1
2 Abbocath no 18
2
2 Abbocath no 20
3
2 Abbocath no 22
4
2 Abbocath no 26
5
2 Kasa pembalut hidrofil
6 4m x 15
2 Kapas pembalut 10cm
7
2 Leukoplast 10cm x 5cm
8
2 Urin bag
9
3 Arm Sling
0
3 Bactigras 10x10
1
3 Bactigras 20x10
2
3 Catgut chromic
3
3 NRM anak
4
3 Nasal kanul
5
3 dermafix
6
3 modres
7
3 Micropore 1 inci
8
3 Micropore 2 inci
9
4 Jarum insulin
0
4 Intrasite gel
1
4 Disposible resucitator
2 set
4 Double spike
3
4 Hecting 16-20
4
4 Hecting 6-15
5
4 Hecting 1-5
6
4 High elastic bandage
7 7,5 cm
4 High elastic bandage
8 10 cm
4 High elastic bandage
9 15 cm
5 Infant ear syringe
0
5 Pemeriksaan asam urat
1
5 Pemeriksaan kolesterol
2
5 Pemeriksaan glukosa
3
5 Pemeriksaan
4 hemoglobin
5 pispot
5
5 Plester anti air
6
5 Rapid tes
7
5 Regulator
8
5 Selang nebu
9
4 Silk braided
5
4 Suction manual
6
4 Tespack
7
4 Tongue cleaner
8
4 underpad
9
5 Wooden tongue
0