1 ACT (Artesunate tablet 50 mg + Amodiaquine n/a PT. Kimia Farma 1 blister@24 tablet 1,375.

00
anhydrida tablet 200 mg)
2 Adefovir Dipivoksil tablet/kaplet 10 mg Hepsera PT. SmithKline Dus, 3 Blister @ 10 kapsul 27,500.00
3 Air untuk irigasi lar infus 1000 ml WIDA WI UNICAP PT. Widatra Bhakti Btl @ 1000 ml 7,500.00
4 Akarbose tablet/kaplet 100 mg n/a PT. Dexa Medica Dus, 10 strip @10tablet 1,397.00
5 Akarbose tablet/kaplet 50 mg n/a PT. Dexa Medica Dus, 10 strip @10tablet 950
6 Albendazol suspensi 200 mg/5 ml n/a PT. Indofarma Dus, 10 dus @ 1 botol @ 10 ml 3,849.00
7 Albendazol tablet/kapsul/kaplet 400 mg n/a PT. Holi Pharma Dus, 5 strip @ 6 tablet 344
Albumin serum normal (human albumin) injeksi Zenalb
8 PT. Ikapharmindo Vial 100 ml 750,000.00
20%, 100 ml
Albumin serum normal (human albumin) injeksi Zenalb
9 PT. Ikapharmindo Vial 50 ml 345,000.00
20%, 50 ml
Albumin serum normal (human albumin) injeksi PLASBUMIN 25% 20 ML
10 PT. Dipa Pharmalab botol @ 20 ml 321,552.00
25%, 20 ml
Albumin serum normal (human albumin) injeksi PLASBUMIN 25% 50 ML
11 PT. Dipa Pharmalab botol @ 50 ml 732,727.00
25%, 50 ml
Albumin serum normal (human albumin) injeksi PLASBUMIN 5% 250 ML
12 PT. Dipa Pharmalab botol @ 250 ml 900,000.00
5% 250 ml
Albumin serum normal (human albumin) injeksi PLASBUMIN 5% 50 ML
13 PT. Dipa Pharmalab botol @ 50 ml 283,000.00
5% 50 ml
14 Alopurinol tablet/kapsul/kaplet 100 mg n/a PT. Pertiwi Agung Box, 10 strips @ 10 tablets 86
15 Alopurinol tablet/kapsul/kaplet 300 mg n/a PT. Bernofarm Dus, 10 blister @ 10 tablet 199.5
16 Alprazolam tablet/kapsul/kaplet 0,25 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 380
17 Alprazolam tablet/kapsul/kaplet 0,5 mg n/a PT. Kimia Farma Ktk 10x10 tablet 214
18 Alprazolam tablet/kapsul/kaplet 1 mg n/a PT. Kimia Farma Ktk 10x10 tablet 233
19 Alteplase injeksi 50 mg/vial Actilyse PT. Boehringer Dus, 1 vial@50mg + 1 vial pelarut @ 5 3,800,000.00
20 Amfoterisin B salep mata 1% Fungicide PT. Cendo tube 3.5 gr 18,500.00
21 Amikasin injeksi 250 mg/ml Glybotic 250 mg /ml PT. Sanbe Farma Vial 2 ml 50,500.00
22 Aminofilin injeksi 24 mg/ml n/a PT. Lucas Djaja dus 30 ampul @10 ml 3,822.00
23 Aminofilin tablet scored 200 mg n/a PT. Erela Botol @100 Tablet 80
24 Aminofilin tablet/kapsul/kaplet 150 mg n/a PT. Erela Btl @ 100 tablet 80
25 Amiodaron injeksi 150 mg/3 ml Cordarone PT. Aventis Pharma Dus, 6 ampul @ 3 ml 12,480.00
26 Amiodaron tablet/kaplet 200 mg Kendaron Tablet PT. Darya Varia strip 1,200.00
27 Amitriptilin tablet salut 25 mg (HCl) n/a PT. Indofarma Dus, 10 strip @ 10 tss 112
28 Amlodipin tablet 10 mg n/a PT. Pertiwi Agung Box, 3 strips @ 10 tablets 330
29 Amlodipin tablet 5 mg n/a PT. Pertiwi Agung Box, 3 strips @ 10 tablets 187
30 Amoksisilin kapsul/kaplet 250 mg n/a PT. Novapharin dus 10 X 10'S 211
31 Amoksisilin kapsul/kaplet/tablet scored 500 mg n/a PT. Mersifarma KOTAK @ 10 x 10 TAB 261
32 Amoksisilin sirup kering forte 250 mg/5 ml n/a PT. Holi Pharma Dus, Botol 60 ml 4,070.00
33 Amoksisilin sirup kering 125 mg/ 5 ml n/a PT. Novapharin btl @ 60 ml 2,445.00
34 Ampisilin serbuk injeksi i.v. 1000 mg/vial n/a PT. Bernofarm Dus, 10 vial @ 1 g 5,100.00
Analog insulin long acting inj 100 UI/ml, Lantus Solostar 100IU/ml 5pens PT. Aventis Pharma
35 vial/cartridge disposible/penfill cartridge dus, 5 solostar pen @ 3ml 85,000.00
x3ml
(Insulin glargine
Analog insulin 100
mix IU/ml)
acting inj 100 UI/ml, Analog
insulin mix acting inj 100 UI/ml (Premix 30%
36 Novomix Flexpen PT. Ferron Injeksi 100 IU/ml, Flexpen disposible 3 106,000.00
Insulin Aspart + 70% Protaminated Insulin
Analog insulin mix insulininj 100 UI/ml,
Aspart (Analogue))
37 vial/cartridge disposible/penfill cartridge (25% Humalog Mix 25 PT. Bayer Indonesia Penfill cartridge 97,500.00
insulin lispro, 75% insulin lispro protamine
suspension,
Analog (rDNA))
insulin rapid acting inj 100 UI/ml,
38 vial/cartridge disposible/penfill cartridge Novorapid Vial PT. Ferron Dus, vial 10 ml 200,000.00
(Insulin Aspart (Analogue))
Analog insulin rapid acting inj 100 UI/ml,
39 vial/cartridge disposible/penfill cartridge Novorapid Flexpen PT. Ferron Injeksi 100 IU/ml, Flexpen disposible 3 85,345.00
(Insulin Aspart (Analogue))
Analog insulin rapid actinginj 100 UI/ml, Apidra Solostar 100IU/ml 5pens PT. Aventis Pharma
40 vial/cartridge disposible/penfill cartridge dus, 5 solostar pen @ 3ml 79,165.00
x3ml
(Insulin glulisine 100 IU/ml)
Analog insulin rapid actinginj 100 UI/ml,
41 vial/cartridge disposible/penfill cartridge Humalog PT. Bayer Indonesia Penfill cartridge 79,167.00
(Insulin lispro (rDNA origin))
42 Anastrozol tablet/kapsul/kaplet 1 mg Arimidex 1 mg PT. Astra Dus, 2 blister @ 14 Tablet 32,000.00
Antasida DOEN I tablet kunyah, kombinasi :
43 Aluminium Hidroksida 200 mg Magnesium n/a PT. Erela Dus, 10 Strip @ 10 Tablet 72
Hidroksida 200 mg
Antasida DOEN II suspensi, kombinasi :
44 Aluminium Hidroksida 200 mg/5 ml n/a PT. Erela Botol @ 60 ml 2,160.00
Magnesium Hidroksida 200 mg/5 ml
Anti Bakteri DOEN salep komb: Basitrasin 500
45 n/a PT. Indofarma Dus, 25 tube @ 5 g 2,516.00
IU/g Polimiksin 10.000 IU/g
Antimalaria DOEN kombinasi : Pirimetamin 25
46 n/a PT. Kimia Farma ktk 10 x 10 tablet 520
mg Sulfadoksin 500 mg
Antimigren: Ergotamin Tartrat 1 mg + Kofein 50
47 n/a PT. Kimia Farma Btl 100 tablet 135
mg
Antiparkinson DOEN tablet kombinasi :
48 Levopar Tablet PT. Meprofarm Dus, 5 strip @ 10 tablet 1,500.00
Benserazid 25 mg Levodopa 100 mg
49 Artemether injeksi 80 mg/ml Artem PT. Kimia Farma Dus 6 amp @ 1ml 22,000.00
50 Asam Asetilsalisilat (asetosal) tablet 100 mg n/a PT. Phapros, Tbk Dus @ 10 X 10 's 116
Asam Asetilsalisilat (asetosal)
51 Miniaspi 80 PT. Mersifarma KOTAK @ 10 x 10 TAB 148
tablet/kaplet/kapsul 80 mg
52 Asam Askorbat (Vitamin C) tablet 250 mg n/a PT. Kimia Farma ktk 10x10 tablet 159
53 Asam Askorbat (Vitamin C) tablet 50 mg n/a PT. Kimia Farma Dus 10 strip x 10 tab 95
54 Asam Folat tablet/kapsul/kaplet 0,4 mg Starfolat PT. Dexa Medica Dus, 10 strip @10 tablet 84
55 Asam Folat tablet/kapsul/kaplet 1 mg n/a PT. Marin Liza Farmasi Botol @ 100 tablet 48
56 Asam Ibandronat injeksi 6mg/6ml Bondronat PT. Boehringer Boks, 1 ampul 2,209,000.00
57 Asam Mefenamat kapsul/kaplet 500 mg n/a PT. Bernofarm Dus, 10 blister @ 10 kaptab ss 112
58 Asam pipemidat kapsul 400 mg Urotractin 400 mg PT. Sanbe Farma Strip 1,815.00
59 Asam traneksamat injeksi 100 mg/ml n/a PT. Hexpharm Dus, 10 ampul @ 5 ml 3,334.00
60 Asam traneksamat injeksi 50 mg/ml n/a PT. Bernofarm Dus, 10 ampul @ 5 ml 2,950.00
61 Asam zoledronat injeksi 4mg/5mL ZOMETA PT. Novartis Dus, 1 vial plastik @ 5ml 900,000.00
62 Asiklovir salep mata 3% Temiral Eye Oint PT. Sanbe Farma Tube 3,5 gram 24,750.00
63 Asiklovir tablet/kapsul/kaplet 200 mg n/a PT. Indofarma Dus, 10 blister @ 10 tablet 237
64 Asiklovir tablet/kapsul/kaplet 400 mg n/a PT. Sampharindo Dus, 5 strip @ 10 tablet 336
65 Asparaginase serbuk injeksi 10.000 UI/vial Leunase PT. Widatra Bhakti 10.000 UI/Vial 1,039,500.00
66 Atapulgit tablet 600 mg Pularex PT. Zenith Dus 5 strip @ 10 tablet 190
67 Atenolol tablet/kapsul/kaplet 100 mg Betablok PT Kalbe Farma strip 700
68 Atrakurium injeksi 25 mg/2,5 ml Tracrium PT. Glaxo Dus, 5 ampul @ 2.5 ml 20,000.00
69 Atropin Sulfat tablet 0,5 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 74
70 Atropin Sulfat tetes mata 0,5% Cendo Tropin 0,5% PT. Cendo Botol 5ml 13,500.00
71 Atropin Sulfat tetes mata 1% Cendo Tropin 1% PT. Cendo Botol 5ml 13,500.00
72 Azitromisin sir kering 200 mg/ 5 mL n/a PT. Soho botol @ 60 ml 34,400.00
73 Azitromisin tablet 500 mg n/a PT. Kimia Farma ktk 2x10 tablet 4,500.00
74 Azitromisin tablet 250 mg n/a PT. Soho Strip 3,333.00
75 Bedak salisil serbuk 2% n/a PT. Rama Dus @ 50 gram 1,250.00
76 Benzatin Benzil Penisilin 1,2 juta IU/ vial n/a PT. Phapros, Tbk Ds 10 vial x 1,2 Jt IU 9,800.00
77 Benzatin Benzil Penisilin 2,4 juta IU/vial n/a PT. Phapros, Tbk 10 vial @ 2.400.000 IU 13,400.00
78 Beractant injeksi / suspensi 25 mg/mL Survanta PT. Abbott Indonesia Vial 3,200,000.00
79 Beraprost sodium tablet 20 mcg Dorner 20 µg PT. Combiphar Box/ 3 blister @ 10 Tablet 3,600.00
80 Betametason krim 0,1% (sebagai Valerat) n/a PT. Kimia Farma Tube 5 gr 1,520.00
81 Betametason tetes mata 1 mg/ml Betam Ophtal ED PT. Sanbe Farma botol @ 5 ml 25,106.00
Bevasizumab injeksi 25 mg/ml (Skema Risk
82 Sharing sesuai Kepmenkes RI Nomor Avastin PT. Boehringer Dus, 1 vial @ 4 ml 4,803,697.00
HK.02.02/Menkes/223/2014)
83 Bikalutamid tablet salut 150 mg Casodex 150 mg PT. Astra Dus, 2 blister @ 14 Tablet 72,400.00
84 Bikalutamid tablet salut 50 mg Casodex 50 mg PT. Astra Dus, 2 blister @ 14 Tablet 45,000.00
85 Bisakodil suppositoria 10 mg Stolax supp PT. Sanbe Farma Supp 6,045.00
86 Bisakodil suppositoria 5 mg Dulcolax Supp Infant PT. Boehringer 1 Box @ 6's 4,990.00
87 Bisoprolol tablet 2,5 mg Concor 2.5 PT. Merck Tbk Dus 10 blister @ 10 tablet 746
88 Bisoprolol tablet 5 mg n/a PT. Pratapa Nirmala Box 3 X 10 tab 645
89 Bleomisin serbuk injeksi 15 mg/ampul BLEOCIN PT Kalbe Farma Vial 304,000.00
90 Bromokriptin tablet 2,5 mg Cripsa tab PT. Caprifarmindo Box 3 x 10'S 247,089.00
91 Budesonid inhaler 200 mcg/puff, 100 dosis Pulmicort Turbuhaler PT. Astra Dus, 1 Turbuhaler @ 100 dosis 93,000.00
92 Budesonid inhaler 200 mcg/puff, 200 dosis Obucort Swinghaler PT Otsuka Indonesia Unit, 200 dosis 106,000.00
93 Budesonid respules / cairan inhaler 0,25mg/mL Pulmicort Respules PT. Astra Dus, 4 pak @ 5 respules @ 2 ml 8,900.00
Budesonid-formoterol (fixed combination) Symbicort Turbuhaler 160/4.5 PT. Astra
94 Dus, 1 Turbuhaler @ 120 dosis 117,600.00
inhaler 160/4,5 mcg mcg
Budesonid-formoterol (fixed combination)
95 Symbicort 80/4.5 mcg PT. Astra Dus, 1 Turbuhaler @ 60 dosis 110,500.00
inhaler 80/4,5 mcg
96 Bupivakain injeksi 0,50% (HCl) + glukosa 8% n/a PT. Dexa Medica Dus, 5 ampul @ 4 ml 25,600.00
97 Bupivakain injeksi 0,50% (P.V) Bunascan PT. Pratapa Nirmala ampul 30,800.00
98 Dabigatran eteksilat kapsul 75 mg Pradaxa PT. Boehringer Dus, 3 blister @ 10 kapsul 12,936.00
99 Dabigatran eteksilat kapsul 110 mg Pradaxa PT. Boehringer Dus, 3 blister @ 10 kapsul 12,936.00
100 Dakarbazin serbuk injeksi 200 mg/vial DBL Dacarbazine PT. Tempo vial @ 20 ml 305,000.00
101 Daunorubisin serbuk injeksi 20 mg/vial DAUNOCIN PT. Novell vial 275,000.00
102 Deferasiroks tablet disp/ eff 250 mg Exjade 250 mg Tab PT. Novartis Dus, 4 blister @ 7 tablet 76,000.00
103 Deferasiroks tablet disp/ eff 500 mg Exjade 500 mg Tab PT. Novartis Dus, 4 blister @ 7 tablet 150,000.00
104 Deferipron larutan oral 100 mg/mL Ferriprox Oral Solution PT. Sydna Farma Dus, Botol @ 500ml 2,600,000.00
105 Deferipron tablet 500 mg Ferriprox tablet PT. Sydna Farma Dus, Botol @ 100 tablet 25,300.00
106 Deferoksamin Mesilat serbuk injeksi 500 mg Desferal PT. Novartis Dus, 10 vial @ 500mg 112,000.00
107 Deksametason injeksi i.v./i.m. 5 mg/ml n/a PT. Indofarma Dus, 100 ampul @ 1 ml 1,580.00
108 Deksametason tablet 0,5 mg n/a Dus, 10 Strip@10 Tablet 62
109 Desogestrel tablet 75 mcg Cerazette PT. Merck Dus, 1 Blister @ 28 tablet 70,000.00
110 Desoksimetason krim 0,25% DEXIGEN PT. Ifars Dus, tube @ 5 g 5,700.00
111 Desoksimetason krim 0,25% n/a PT. Dexa Medica Kotak, tube @ 15 gram 9,983.00
112 Diazepam larutan rektal 5 mg/2,5 mL STESOLID PT. Actavis Dus, 5 alubag @ 1 tube @ 2,5ml 11,525.00
113 Diazepam larutan rektal 10 mg/2,5 mL STESOLID PT. Actavis Dus, 5 alubag @ 1 tube @ 2,5ml 16,748.00
114 Diazepam tablet 2 mg n/a PT. Kimia Farma Btl 100 45
115 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) n/a PT. Phapros, Tbk Dus @ 30 Ampul 1,050.00
116 Digoksin injeksi 0,25 mg/ml Fargoxin inj PT. Pratapa Nirmala Box @ 5 ampul 2 mL 22,000.00
117 Digoksin tablet 0,25 mg n/a PT. Yarindo Box 10 X 10 Tab 97
118 Diltiazem HCl tablet 30 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 134
Herbesser Powder Injection
119 Diltiazem infus injeksi 50 mg PT. Tanabe Indonesia 10 vial @ 50mg 127,667.00
50mg
120 Diltiazem injeksi 25 mg/5 mL Farmabes Injeksi 25 mg PT. Pratapa Nirmala Vial 5 mL 46,667.00
121 Diltiazem Kapsul SR 100 mg Herbesser CD 100 PT. Tanabe Indonesia 3 blister @ 10 kapsul 3,667.00
122 Diltiazem Kapsul SR 200 mg Herbesser CD 200 PT. Tanabe Indonesia 3 blister @ 10 kapsul 4,015.00
123 Dimenhidrinat tablet 50 mg n/a PT. Kimia Farma Btl 100 tablet 104
124 Dinatrium edetat tetes mata 0,35% E.D.T.A PT. Cendo botol 15 ml 37,500.00
125 Dinatrium klodronat infus kons 60 mg/mL Bonefos Infus 60 mg / 5 ml PT. Bayer Indonesia ampul 124,955.00
126 Dobutamin injeksi 50 mg/mL DOBURAN PT. Dipa Pharmalab ampul @ 5 ml 26,700.00
127 Doksazosin mesilat tablet 1 mg Cardura 1mg PT. Pfizer Indonesia Dus, 5 blister @10's tab 3,480.00
128 Doksazosin mesilat tablet 2 mg Cardura 2mg PT. Pfizer Indonesia Dus, 5 blister @10's tab 5,480.00
129 Doksisiklin tablet/kapsul/kaplet 100 mg n/a PT. Yarindo Box @ 10 strip 10 kapsul 270
130 Doksorubisin serbuk injeksi i.v. 10 mg/vial Doxorubicin Actavis 10 mg PT. Actavis Dus, 1 vial @ 10 mg 55,500.00
131 Doksorubisin serbuk injeksi i.v. 50 mg/vial Doxorubicin Actavis 50 mg PT. Actavis Dus, 1 vial @ 50 mg 258,000.00
132 Domperidon suspensi/sirup 5 mg/5 ml n/a PT. Novapharin btl @ 60 ml 3,333.00
133 Domperidon tablet 10 mg n/a PT. Novapharin dus 10 X 10'S 167
134 Domperidon tetes 5 mg/mL n/a PT. Bernofarm Dus, botol @ 10 ml 15,600.00
135 Dopamin injeksi 40 mg/ml UDOPA PT. Dipa Pharmalab ampul @ 5 ml 9,840.00
136 Dosetaksel injeksi 20 mg/0,5 ml n/a PT. Sanbe Farma Dus, 1 vial @0,5 ml+ 1 vial pelarut @1 970,200.00

137 DTPA (diethylene triamine pentaacetic acid) Renalscan KaeF PT. Kimia Farma Dus @ 5 vial 455,000.00
2,06-2,5 mg pentetate calcium trisodium/mL
138 Dutasterid kaps lunak 0,5 mg Avodart PT. SmithKline Dus, Botol Plastik @ 30 Tablet 7,100.00
139 Efavirens tablet salut 600 mg n/a PT. Kimia Farma Botol 30 tab 6,375.00
140 Efedrin Inj 50 mg/ml n/a PT. Bernofarm Ampul @ 1 ml 12,990.00
141 Eksemestan tablet 25 mg Aromasin PT. Pfizer Indonesia Dus, 2 blister @ 15 tablet 42,600.00
142 Enoksaparin sodium inj 20 mg/0,2 mL Lovenox 2000 ANTI-XA PT. Aventis Pharma dus, 2 prefilled syringe @ 0,2 ml 40,740.00
143 Enoksaparin sodium inj 40 mg/0,4 mL Lovenox 4000 ANTI-XA PT. Aventis Pharma dus, 2 prefilled syringe @ 0,4 ml 71,875.00
144 Enoksaparin sodium inj 60 mg/0,6 mL Lovenox 6000 ANTI-XA PT. Aventis Pharma dus, 2 prefilled syringe @ 0,6 ml 100,000.00
145 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml n/a PT. Phapros, Tbk Dus @ 30 Ampul 8,100.00
146 Epirubisin serb injeksi 50 mg/25ml Epirubisin Kalbe PT Kalbe Farma Vial @ 25 ml 500,000.00
147 Epirubisin serb injeksi 10 mg/5 ml n/a PT. Sanbe Farma Dus, 1 vial @5 ml 128,000.00
148 Ergokalsiferol (vitamin D3/D2) kapsul 50.000 UI D-Vit FT PT. Gracia Pharmindo Dus 3 strip @ 10 Flash tablet 650
149 Ergokalsiferol (vitamin D3/D2) suspensi 10.000 D-Vit Syrup PT. Gracia Pharmindo Dus, Botol Plastik @ 100 mL 8,000.00
UI/ml
150 Eritromisin kapsul/kaplet 250 mg n/a PT. Kimia Farma ktk 10 x 10 kapsul 497
151 Eritromisin kapsul/kaplet 500 mg n/a PT. Indofarma Dus, 10 blister @ 10 kss 930
152 Eritromisin sirup kering 200 mg/ 5 ml n/a PT. Phyto Botol @60 ml 7,700.00
153 Eritropoetin-alfa inj 10000 UI/mL Hemapo 10.000 IU PT Kalbe Farma vial/ampul (Prefilled Syringe) 275,000.00
154 Eritropoetin-alfa inj 2000 UI/mL Eprex 2000 PT. Soho Dus, 6 prefilled syrenge @ 0.5 ml 133,875.00
155 Eritropoetin-alfa inj 3000 UI/mL Hemapo 3000 PT Kalbe Farma Prefilled Syringe @ 1ml 128,000.00
156 Eritropoetin-beta inj 2000 UI/0,3 mL Recormon PT. Boehringer Boks, 6 ampul 139,500.00
157 Etambutol tablet 250 mg (HCl) n/a PT. Kimia Farma ktk 20 x 10 tablet 314
158 Etambutol tablet salut 500 mg (HCl) n/a PT. Indofarma Dus, 10 strip @ 10 tss 451
159 Etanol 70% cairan n/a PT. Novapharin btl @ 100 ml 2,500.00
160 Etinilestradiol tablet 0,05 mg Lynoral PT. Merck Dus, botol @ 100 tablet 1,360.00
161 Etonogestrel implan 68 mcg Implanon PT. Merck Dus, 1 blister @ 1 subdermal implant 128,779.00
162 Etoposid injeksi 20 mg/ml Posyd PT. Combiphar Vial 100mg/5ml 100,000.00
163 Eugenol cairan n/a PT. Kimia Farma Botol 10 ml 16,667.00
164 Everolimus tab 0,25 mg Certican 0,25 mg Tab PT. Novartis Dus, 6 blister @ 10 tablet 11,813.00
165 Everolimus tab 0,5 mg Certican 0,5 mg Tab PT. Novartis Dus, 6 blister @ 10 tablet 23,250.00
Faktor koagulasi II 14-35 UI, faktor koagulasi VII
166 7-20 UI, faktor koagulasi IX 25 UI, faktor Coffact 500 IU/20 ml PT. Graha Farma Dual, vial 500 IU 4,400,000.00
koagulasi X 14-35 UI
167 Faktor VIIa (rekombinan) serb inj 1 mg/vial + Novoseven PT. Ferron KOTAK @ 1 VIAL SERBUK OBAT & INFU 9,200,000.00
pelarut untuk injeksi
168 Faktor VIII (konsentrat) serb inj 230 -340 UI Haemoctin PT. Kimia Farma vial 1,133,000.00
169 Faktor VIII (konsentrat) serb inj 250 UI/vial + Haemoctin PT. Kimia Farma vial 990,000.00
pelarut 5 mL
170 Faktor VIII (konsentrat) serb inj 480 - 600 UI KOATE DVI 500 IU PT. Dipa Pharmalab vial 2,150,000.00
171 Fenitoin injeksi 50 mg/ml n/a PT. Mersifarma KOTAK @ 10 ampul 20,250.00
172 Fenitoin kapsul/kaplet 100 mg n/a PT. Ikapharmindo Botol @ 100 133
173 Fenitoin Na Inj 100 mg/2 ml n/a PT. Mersifarma KOTAK @ 10 ampul 20,250.00
174 Fenobarbital injeksi i.m./i.v. 50 mg/ml n/a PT. Phapros, Tbk Dus @ 30 Ampul 1,800.00
175 Fenofibrat kaps 100 mg n/a PT. Hexpharm Dus, 3 strip @ 10 kapsul 1,075.00
176 Fenofibrat kaps 300 mg n/a PT. Hexpharm Dus, 3 strip @ 10 kapsul 1,375.00
177 Fenoksimetil penisilin (penisilin V) tablet 250 n/a PT. Phapros, Tbk Dus @ 10 X 10 's 290
mg
178 Fenoksimetil penisilin (penisilin V) tab 125 mg Fenocin PT. Actavis Dus 45 x 12 tab 235
179 Fenoksimetil penisilin (penisilin V)tablet 500 mg n/a PT. Phapros, Tbk Dus @ 10 X 10 's 510
180 Fenoterol HBr ih 100 mcg/puff Berotec MDI PT. Boehringer Box, canister 10mL 72,900.00
181 Fenoterol HBr inh solution 0,1% Berotec Solution PT. Boehringer Dus, Canister 200 dosis 117,500.00
182 Fentanil injeksi i.m/i.v 0,05 mg/ml, ampul 10 ml n/a PT. Kimia Farma Dus 5 ampul@ 10ml 128,000.00
183 Fentanil injeksi i.m/i.v 0,05 mg/ml, ampul 2 ml n/a PT. Kimia Farma Dus 5 ampul@ 2ml 33,914.00
184 Fentanil patch 12,5 mcg/jam Durogesic 12,5 MU Matrix PT. Kimia Farma Dus @ 5 patch 80,000.00
185 Fentanil patch 25 mcg/jam Durogesic 25 MU Matrix PT. Kimia Farma Dus@ 5 patch 153,000.00
186 Fentanil patch 50 mcg/jam Durogesic 50 MU Matrix PT. Kimia Farma Dus@ 5 patch 285,000.00
187 Filgrastim inj 300 mcg/mL Leucogen PT Kalbe Farma pfs @ 0,5 ml 375,000.00
188 Finasterid tab 5 mg Prostacom PT. Combiphar Box, isi 3 Strip @ 10 tab 2,950.00
189 Fitomenadion (Vit.K1) tablet salut gula 10 mg n/a PT. Phapros, Tbk Dus @ 10 X 10 's 630
190 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml n/a PT. Phapros, Tbk dus @ 30 ampul 3,417.00
191 Fludarabin inj 50 mg Fludara IV LYO PT. Aventis Pharma Dus, 5 vial @ 50 mg 1,248,319.00
192 Fludarabin tab 10 mg Fludara Oral PT. Aventis Pharma Dus, 4 blister @ 5 tablet salut selaput 275,000.00
193 Flufenazin injeksi i.m. 25 mg/ml Sikzonoate Injeksi PT. Mersifarma Dus, 5 ampul @ 1ml 55,000.00
194 Flukonazol injeksi 2 mg/ml n/a PT. Natura Dus, 1 Botol @ 100 mL 47,550.00
195 Flukonazol tablet/kaplet/kapsul 50 mg Diflucan 50mg PT. Pfizer Indonesia Blister 4,862.00
196 Flukonazol tablet/kapsul 150 mg n/a PT. Kimia Farma ktk 1 x 10 kapsul 22,000.00
197 Fluoksetin tablet 10 mg Foransi 10 PT. Gracia Pharmindo strip 419
198 Fluoksetin tablet 20 mg NOPRES PT. Dexa Medica DUS, 30 TABLET 432
199 Fluorometolon tetes mata 0,1 % Ocuflam ED PT. Sanbe Farma botol @ 5 ml 30,493.00
200 Fluorourasil inj 250 mg/mL Curacil PT Kalbe Farma vial @ 1 ml 24,500.00
201 Fluorourasil inj 500 mg/ 5 mL Curacil PT Kalbe Farma vial @ 10 ml 33,000.00
202 Flusinolon asetonid krim 0,025% SYNARCUS PT. Ifars Dus, Tube 5 g 2,400.00
203 Flutikason furoat intranasal spray Avamys PT. Glaxo Dus, Botol 120 Dosis Spay 93,333.00
204 Flutikason propionat nebules 0,5 mg Flixotide Nbules PT. Glaxo Dus, 2 flow wrap@ 5 nebules @ 1 dosi 12,917.00
205 Fondaparinuks inj 2,5 mg/0,5 mL Arixtra PT. Glaxo Dus, 2 pfs 0.5 ml 241,667.00
206 Fraksi protein plasma lar inf 5% Plasmanate PT. Dipa Pharmalab dus, vial @ 250 ml 972,000.00
207 Furosemid injeksi i.v./i.m. 10 mg/ml n/a PT. Indofarma Dus, 25 ampul @ 2 ml 1,829.00
208 Furosemid tablet 40 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 85
209 Gadobutrol macrocyclic 5 mg Gadovist 5 mg PT. Bayer Indonesia Prefilled Syringe 275,000.00
210 Gadobutrol macrocyclic 7,5 mg Gadovist 7,5 mg PT. Bayer Indonesia Prefilled Syringe 412,500.00
211 Gadoksetat disodium 0,25 mmol gadoxetate Primovist PT. Bayer Indonesia Prefilled Syringe 2,570,000.00
disodium/mL
212 Gansiklovir serb inj 500 mg (50 mg/mL) Cymevene PT. Boehringer Boks, 1 ampul 399,500.00
 Garam Oralit I serbuk, kombinasi : Natrium
213 klorida 0,52 g kalium klorida 0,30 g Trinatrium n/a PT. Phapros, Tbk Dus @ 100 Sachet 288
sitrat dihidrat 0,58 g Glukosa Anhidrat 2,70 g
214 Gefitinib tab 250 mg Iressa 250 mg PT. Astra Dus, 1 blister @ 10 tablet 295,000.00
215 Gemfibrozil kapsul/kaplet 300 mg n/a PT. Indofarma Dus, 10 blister @ 12 kapsul 289
216 Gemfibrozil tablet 600 mg n/a PT. Indofarma Dus, 10 blister @ 10 kaptab 679
217 Gemsitabin inj 1000 mg/vial Gemzar 1000 mg PT. Bayer Indonesia vial 1,098,900.00
218 Gemsitabin inj 200 mg/vial n/a PT. Sanbe Farma Dus, 1 vial @200 mg 330,000.00
219 Gentamisin injeksi 40 mg/ ml n/a PT. Indofarma Dus, 5 ampul @ 2 ml 3,399.00
220 Gentamisin salep mata 0,3% Genoint Salep Mata PT. Erela Tube @ 3,5 gr 2,600.00
221 Gentamisin tetes mata 0,3% n/a PT. Indofarma Dus, botol plastik 5 ml 3,194.00
222 Glibenklamid tablet 5 mg n/a PT. Indofarma Dus, 10 blister @ 10 kaptab 56
223 Gliklazid tab 80 mg GLUCODEX PT. Dexa Medica DUS, 100 TABLET 236
224 Gliklazid tab 30 mg Diamicron MR 30 PT. Pradja Pharin Dus, 6 strip @ 10 tablet lepas lambat 638
225 Glikuidon tab 30 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 950
226 Glimepiride tablet 1 mg n/a PT. Kimia Farma ktk 5x10 tablet 265
227 Glimepiride tablet 2 mg n/a PT. Kimia Farma ktk 5x10 tablet 436
228 Glimepiride tablet 3 mg n/a PT. Kimia Farma ktk 5x10 tablet 404
229 Glimepiride tablet 4 mg n/a PT. Kimia Farma ktk 5x10 tablet 430
230 Glipizid tablet/kaplet/kapsul 10 mg Glucotrol 10 mg PT. Pfizer Indonesia Dus, botol@TAB 10MG 30 3,207.00
231 Glipizid tablet/kaplet/kapsul 5 mg Glucotrol 5 mg PT. Pfizer Indonesia Dus, botol@TAB 10MG 31 3,000.00
232 Gliseril trinitrat kaps SR 2,5 mg Nitrokaf Retard PT. Kimia Farma Dus 10x10 1,493.00
233 Gliseril trinitrat kaps SR 5 mg Nitrokaf Forte PT. Kimia Farma Dus 10x10 2,171.00
234 Gliseril trinitrat tab sublingual 0,5 mg Nitral PT. Actavis Btl @ 30 tablet 1,500.00
235 Gliserin lar 50% Gliserin lar 50% PT. Lucas Djaja Glycerin 100 ml 5,333.00
236 Glukosa larutan infus 10 % steril n/a PT. Widatra Bhakti botol @ 500 ml 5,700.00
237 Glukosa larutan infus 5 % steril n/a PT. Widatra Bhakti botol @ 500 ml 5,200.00
238 Goserelin asetat inj 10,8 mg/vial Zoladex 10,8 mg PT. Astra Dus, 1 syringe @ 10.8 mg 2,300,000.00
239 Goserelin asetat inj 3,6 mg Zoladex 3,6 mg PT. Astra Dus, 1 syringe @ 3.6 mg 840,000.00
240 Griseofulvin tablet 125 mg n/a PT. Phapros, Tbk Dus @ 10 X 10 's 209
241 Haloperidol inj 50 mg/mL Haldol Decanoas PT. Soho Dus 5 Ampul@1mL 83,333.00
242 Haloperidol injeksi i.m 5 mg/ml Lodomer Injeksi PT. Mersifarma KOTAK @ 12 ampul 6,250.00
243 Haloperidol tablet 0,5 mg n/a PT. Indofarma Dus, 10 blister @ 10 tablet 59
244 Haloperidol tablet 5 mg n/a PT. Indofarma Dus, 10 blister @ 10 tablet 96
245 Haloperidol tablet 1,5 mg n/a PT. Indofarma Dus, 10 blister @ 10 tablet 69
246 Haloperidol tablet 2 mg Lodomer 2 PT. Mersifarma KOTAK @ 10 x 10 TAB 126
247 Haloperidol tts 2 mg/mL LODOMER DROPS PT. Mersifarma BOTOL @ 15 ML 16,500.00
248 Halotan Inhalasi Halothane PT. Dexa Medica Botol 641,500.00
249 Heparin injeksi i.v./s.k. 5000 UI/ml Inviclot PT. Pratapa Nirmala vial 42,900.00
250 Hepatitis B imunoglobulin (human) Hyperhep B PT. Dipa Pharmalab Dus, 1 syringe @ 0.5 mL 1,328,000.00
251 Hidrokortison krim 1% n/a PT. Marin Liza Farmasi tube @ 5 ml 2,570.00
252 Hidrokortison krim 2,5 % n/a PT. Kimia Farma Tube 5 gr 2,798.00
253 Hidroksi Urea tablet/kaplet/kapsul 500 mg HYDROXYUREA MEDAC PT. Dipa Pharmalab vial 5,400.00
254 Hiosin butilbromid injeksi 20 mg/ml n/a PT. Otto box 5ampul @1 ml 4,500.00
255 Homatropin tetes mata 2% Homatro 2% PT. Cendo Botol 5ml 18,000.00
Human insulin intermediate acting inj 100
256 UI/ml, vial (Human Insulin (Intermediate- Insulatard Vial PT. Ferron Dus, vial 10 ml 138,000.00
Acting))
257 Human insulin intermediate acting inj 100 Humulin N Vial PT. Bayer Indonesia Dus, vial 10 ml 138,000.00
UI/ml, vial (Insulin human Basal)

258 Human insulin intermediate acting inj 100

UI/ml, vial/cartridge disposible/penfill cartridge n/a PT. Aventis Pharma Dus, 1 Vial @ 5 ml 72,000.00
Human insulin intermediate acting inj 100
259 UI/ml,penfill cartridge (Human Insulin Insulatard Penfill PT. Ferron Injeksi 100 IU/ml, penfill disposible 3 m 76,125.00
(Intermediate-Acting))
260 Human insulin intermediate acting inj 100 Humulin N Cart PT. Bayer Indonesia Dus Isi 5 penfill/cartridge @ 3ml 76,125.00
UI/ml,penfill cartridge (Insulin human Basal)

261 Human insulin intermediate acting inj 100 Sansulin N PT. Sanbe Farma penfillcartridge @ 3ml 75,000.00
UI/ml,penfill cartridge (Insulin human Basal)
Human insulin mix insulin inj 100 UI/ml, penfill
262 cartridge (Human Insulin (Premix: 30% Soluble Mixtard Penfill PT. Ferron Injeksi 100 IU/ml, penfill disposible 3 m 76,125.00
+ 70 % NPH Insulin))
263 Human insulin mix insulin inj 100 UI/ml, penfill Humulin 30/70 Cart PT. Bayer Indonesia Dus Isi 5 penfill/cartridge @ 3ml 76,125.00
cartridge (Insulin human Comb)
Human insulin mix insulin inj 100 UI/ml, vial
264 (Human Insulin (Premix: 30% Soluble + 70 % Mixtard Vial PT. Ferron Dus, vial 10 ml 138,000.00
NPH Insulin))
265 Human insulin mix insulin inj 100 UI/ml, vial Humulin 30/70 Vial PT. Bayer Indonesia Dus, vial 10 ml 138,000.00
(Insulin human Comb)

266 Human insulin short acting inj 100 UI/ml,

penfill cartridge (Human Insulin (Short Acting)) Actrapid Penfill PT. Ferron Injeksi 100 IU/ml, penfill disposible 3 m 76,125.00
267 Human insulin short acting inj 100 UI/ml, Sansulin R PT. Sanbe Farma penfill cartridge @ 3ml 75,000.00
penfill cartridge (Insulin human Rapd)

268 Human insulin short acting inj 100 UI/ml, Humulin R Cart PT. Bayer Indonesia Dus Isi 5 penfill/cartridge @ 3ml 76,125.00
penfill cartridge (Insulin human Rapd)

269 Human insulin short acting inj 100 UI/ml, vial Actrapid Vial PT. Ferron Dus, vial 10 ml 138,000.00
(Human Insulin (Short Acting))

270 Human insulin short acting inj 100 UI/ml, vial Humulin R Vial PT. Bayer Indonesia Dus, vial 10 ml 138,000.00
(Insulin human Rapd)

271 Human insulin short acting inj 100 UI/ml, n/a PT. Aventis Pharma Dus, 1 Vial @ 5 ml 72,000.00
vial/cartridge disposible/penfill cartridge
272 Human tetanus imunoglobulinn injeksi i.m. 250 Tetagam PT. Dexa Medica Prefilled syringe 170,000.00
UI
273 Ibuprofen sirup 100 mg/5 ml n/a PT. Indofarma Dus, botol 60 ml 3,499.00
274 Ibuprofen suspensi 200 mg/5 ml n/a PT. Indofarma Dus, botol 60 ml 4,499.00
275 Ibuprofen tablet 200 mg n/a PT. Yarindo botol @ 100 tablet 110
276 Ibuprofen tablet 400 mg n/a PT. Novapharin dus 10 X 10'S 150
277 Ifosfamid serbuk injeksi 1000 mg/vial Holoxan injeksi 1000 PT. Mugi Laboratories Dus, 1 vial @ 1 g 1,329,163.00
Imanitib Mesilat tablet salut selaput 100 mg
278 (Skema Risk Sharing sesuai Kepmenkes RI Glivec PT. Novartis Dus, 6 blister @ 10 tablet salut selaput 211,000.00
Nomor HK.02.02/Menkes/223/2014)
279 Imidapril tab 10 mg Tanapress 10mg PT. Tanabe Indonesia 3 blister @ 10 tablet 3,908.00
280 Imidapril tab 5 mg Tanapress 5mg PT. Tanabe Indonesia 3 blister @ 10 tablet 2,120.00
281 Iopamidol 200-300 mg Iodium/mL (300mg @ Iopamiro PT. Dipa Pharmalab Dus, botol @ 100 ml 350,000.00
vial 100ml)
282 Iopamidol 200-300 mg Iodium/mL (300mg @ Iopamiro PT. Dipa Pharmalab Dus, vial @ 30 ml 122,000.00
vial 30ml)
283 Iopamidol 200-300 mg Iodium/mL (300mg @ Iopamiro PT. Dipa Pharmalab Dus, vial @ 50 ml 166,000.00
vial 50ml)
284 Iopamidol 300-370 mg Iodium/mL (370mg @ Iopamiro PT. Dipa Pharmalab Dus, botol @ 100 ml 369,000.00
vial 100ml)
285 Iopamidol 300-370 mg Iodium/mL (370mg @ Iopamiro PT. Dipa Pharmalab Dus, vial @ 30 ml 147,000.00
vial 30ml)
286 Iopamidol 300-370 mg Iodium/mL (370mg @ Iopamiro PT. Dipa Pharmalab Dus, vial @ 50 ml 199,000.00
vial 50ml)
287 Iopromide 300-370 mg Iodium/mL (300 mg / Ultravist 300/100 mg PT. Bayer Indonesia Botol 245,000.00
100 ml)
288 Iopromide 300-370 mg Iodium/mL (300 mg / Ultravist 300/50 mg PT. Bayer Indonesia Botol 123,200.00
50 ml)
289 Iopromide 300-370 mg Iodium/mL (370 mg / Ultravist 370/100 mg PT. Bayer Indonesia Botol 299,000.00
100 ml)
290 Iopromide 300-370 mg Iodium/mL (370 mg / Ultravist 370/50 mg PT. Bayer Indonesia Botol 150,300.00
50 ml)
291 Ipratropium bromida inhalasi 20 mcg/semprot Atrovent HFA PT. Boehringer Box, canister 10mL 80,000.00
Atrovent solution for inhalation
292 Ipratropium bromida nebulizer 0,025% PT. Boehringer Box, bottle 20mL 90,000.00
0.025%
293 Irbesartan tab 150 mg n/a PT. Indofarma Dus, 5 blister @ 10 kss 1,425.00
294 Irbesartan tab 300 mg n/a PT. Indofarma Dus, 5 blister @ 10 kss 2,470.00
295 Irinotekan inf 20 mg/ml n/a PT. Sanbe Farma Dus, 1 vial @2 ml 510,000.00
296 Isofluran inhalasi Terrell PT. Pratapa Nirmala Botol 100 mL 270,000.00
297 Isoniazid tablet/kapsul/kaplet 100 mg n/a PT. Phyto Botol 100 tablet 65
298 Isoniazid tablet/kapsul/kaplet 300 mg n/a PT. Phyto Botol 100 tablet 158
299 Isosorbid Dinitrat injeksi i.v 10 mg/10 ml Farsorbid inj PT. Pratapa Nirmala vial 33,000.00
300 Isosorbid Dinitrat tablet sublingual 5 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 88
301 Isosorbid dinitrat tablet/kaplet/kapsul 10 mg Isonat PT. Kimia Farma Dus, 5 strip @ 10 tablet 189
302 Kalium aspartat tab 300 mg Kalipar PT. Tempo Strip 700
303 Kalium Klorida tablet 600 mg KSR PT. Merck Tbk Dus, 10 strip @ 10 tablet 1,580.00
304 Kalsium Folinat (Leukovorin Ca) inj 50 mg/ml DBL Leucovorin PT. Tempo Vial 50 mg/5 ml 82,000.00
305 Kalsium Glukonat injeksi i.v 10% (100 mg/ml) Kalsium glukonat PT. Ethica Ampul 7,800.00
306 Kalsium Laktat (Kalk) tablet/kapsul/kaplet 500 n/a PT. Afifarma Dus,10 Strip @ 10 tablet 70
mg
307 Kalsium polistirena sulfonat ktg 5 g KALQUEST PT. Novell kantong 5 g 7,700.00
308 Kanamisin inj 1000 mg/ vial n/a PT. Hexpharm vial 5,000.00
309 Kandesartan tab 16 mg n/a PT. Dexa Medica Dus, 3 Blister @ 10 tablet 4,900.00
310 Kandesartan tab 8 mg n/a PT. Dexa Medica Dus, 3 Blister @ 10 tablet 3,100.00
311 Kapesitabin tab 500 mg Xeloda PT. Boehringer Boks, 120 tablet 27,500.00
312 Kaptopril tablet 50 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 140
313 Kaptopril tablet scored 25 mg n/a PT. Errita Pharma Dus, 10 strip @10 tablet 84
314 Kaptopril tablet scored12,5 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 62
Tegretol Syrup 100mg/5ml,
315 Karbamazepin sirup 100 mg/5 ml PT. Novartis Dus, botol @ 120 ml 44,770.00
120ml
316 Karbamazepin tablet 200 mg n/a PT. Indofarma Dus, 10 blister @ 10 tablet 245
317 Karbimazol tab 5 mg Neo-Mercazole PT. Nicholas Dus,botol 100 tablet 875
318 Karbogliserin tetes telinga 10% Karbogliserin tetes telinga 10% PT. Lucas Djaja Fenol 100 mg / 1 ml 2,042.00
319 Karboplatin 150 mg / 15 ml DBL Carboplatin 150 mg PT. Tempo vial @ 15 ml 190,000.00
320 Karboplatin 450 mg / 45 ml DBL Carboplatin 450 mg PT. Tempo vial @ 45 ml 408,000.00
321 Karvediol tablet/kaplet/kapsul 6,25 mg V - BLOC PT Kalbe Farma strip 1,360.00
322 Ketamin injeksi i.v. 100 mg/ml KTM PT. Guardian Vial @ 10 ml 110,000.00
323 Ketamin injeksi i.v. 50 mg/ml Ketamin Hameln PT. Combiphar Box, isi 1 vial @ 10 ml 60,300.00
324 Ketokonazol krim 2% n/a PT. Novell Box isi 1 Tube @ 15 g 4,700.00
325 Ketokonazol krim 2% n/a PT. Hexpharm tube 5 gr 2,850.00
326 Ketokonazol krim 2% n/a PT. Kimia Farma tube 10 gr 2,569.00
327 Ketokonazol scalp sol 2% Zoloral SS PT. Ikapharmindo Botol 80 ml 28,000.00
328 Ketokonazol tablet 200 mg n/a PT. Dexa Medica Dus, 5 Strip @ 10 tablet 300
329 Ketoprofen supositoria 100 mg Protofen Supp PT. Kimia Farma dus 2 's @ 10 supp 2,722.00
330 Ketorolac injeksi 30 mg/ml n/a PT. Phapros, Tbk Dus @ 12 Ampul 2,300.00
331 Klaritromisin tab 500 mg ORIXAL PT. Ifars Dus, 3 Strip @ 10 Kaplet salut selaput 3,200.00
332 Klindamisin kapsul/kaplet 150 mg n/a PT. Indofarma Dus, 5 blister @ 10 kapsul 361
333 Klindamisin kapsul/kaplet 300 mg n/a PT. Indofarma Dus, 5 blister @ 10 kapsul 553
334 Klobazam tab 10 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 900
335 Klonidin injeksi i.v 0,15 mg/ml (HCL) (150) Catapres Injeksi PT. Boehringer Box, 10 ampoules @ 1mL 30,600.00
336 Klonidin tablet 0,15 mg n/a PT. Kimia Farma Ktk 10X10 TAB 184
337 Klopidogrel tab 75 mg n/a PT. Hexpharm Dus, 3 strip @ 10 tab 3,400.00
338 Kloramfenikol kapsul/kaplet 250 mg n/a PT. Kimia Farma ktk 10x10 tablet 249
339 Kloramfenikol salep mata 1 % n/a PT. Kimia Farma Tube 5 gr 1,600.00
340 Kloramfenikol serb inj 1000 mg/mL Colsancetine Injeksi PT. Sanbe Farma vial 7,260.00
341 Kloramfenikol suspensi 125 mg/ 5 ml n/a PT. Bernofarm Botol @ 60 ml 3,680.00
342 Klorpromazin injeksi i.m. 25 mg/ml (HCl) n/a PT. Phapros, Tbk Dus @ 30 Ampul 1,100.00
343 Klorpromazin injeksi i.m 5 mg/ml - 2 ml (HCl) n/a PT. Phapros, Tbk Dus @ 30 Ampul 1,050.00
344 Klorpromazin tablet salut 100 mg (HCl) n/a PT. Mersifarma Kotak @ 10 x 10 tab 144
345 Klorpromazin tablet salut 25 mg (HCl) n/a PT. Phapros, Tbk 10 X 10 68
346 Klozapin 100 mg n/a PT. Mersifarma KOTAK @ 5 x 10 TAB 5,000.00
347 Klozapin 25 mg n/a PT. Mersifarma KOTAK @ 5 x 10 TAB 1,550.00
348 Kodein tablet 10 mg n/a PT. Kimia Farma ktk 10x10 tablet 500
349 Kodein tablet 15 mg n/a PT. Kimia Farma ktk 10x10 tablet 850
350 Kodein tablet 20 mg n/a PT. Kimia Farma ktk 10x10 tablet 1,100.00
351 Kolekalsiferol (vitamin D3) kapsul lunak 0,25
mcg Ostriol PT. Pratapa Nirmala Btl @ 30 kapsul 2,500.00
352 Koloid HES BM 130 000 lar inf 6% Voluven PT. Fresenius Botol Plastik @ 500 ml 33,000.00
353 Kombinasi : Ipratropium bromida inhalasi 0,5 Combivent UDV PT. Boehringer 1 dus @ 20 vial 5,990.00
mg Salbutamol 2,5 mg
354 Kombinasi suspensi : Parafin + gliserin + Laxadine Emulsi 60 ml PT. Galenium Botol @ 60 ml 12,450.00
fenolftalein
355 Kombinasi tablet salut : Besi (II) sulfat 7H2O n/a PT. Erela Dus, 100 Sachet @ 30 Tablet 42
200 mg Asam folat 0,25 mg
356 Kombinasi tablet salut : Besi (II) sulfat 7H2O n/a PT. Kimia Farma 1 sase @30 tablet 50
200 mg Asam folat 0,25 mg
357 Kombinasi tetes mata 2,5 mg/mL: Natrium Cendo Lyteers PT. Cendo botol 15 ml 15,750.00
klorida 8,664 mg; Kalium klorida 1,32 mg
358 Kombinasi: Artemether 20 mg; Lumefantrin 120 Coartem PT. Novartis Dus, 4 blister @ 6 tablet 3,220.00
mg
359 Kombinasi: Levodopa 100 mg; Karbidopa 25 Stalevo PT. Novartis Dus, botol plastik @ 30 tablet salut se 8,900.00
mg; Entekapon 200 mg
Kombinasi: Lopinavir 200 mg; Ritonavir (LPV/r)
360 50 mg Aluvia PT. Abbott Indonesia botol @ 120 tablet 6,100.00
Kombinasi: Salmeterol 25 mcg; Flutikason
361 propionat 50 mcg Seretide Inhaler 50 mcg PT. Glaxo Dus, Botol 120 Dosis 90,667.00
Kombinasi: Salmeterol 50 mcg; Flutikason
362 propionat 100 mcg Seretide Diskus 100 mcg PT. Glaxo Dus, foil strip @ 60 dosis 100,833.00
Kombinasi: Salmeterol 50 mcg; Flutikason
363 propionat 250 mcg Seretide Diskus 250 mcg PT. Glaxo Dus, foil strip @ 60 dosis 113,333.00
Kontrasepsi pil oral, kombinasi :*
364 Levonorgestrel 150 mcg Etinilestradiol 30 mcg n/a PT. Kimia Farma Dus, 100 blister @ 28 tablet 2,089.00
365 Kotrimoksazol DOEN I (dewasa) kombinasi : n/a PT. Promedrahardjo Dus, 10 Strip@10 Tablet 138
Sulfametoksazol 400 mg Trimetoprim 80 mg
Kotrimoksazol Suspensi komb:
366 200 mg + Trimetoprim 40 mg / 5 ml Sulfametoksazol n/a PT. Sampharindo Botol, 60 ml 2,167.00
367 Kuinin (Kina) tablet 200 mg n/a PT. Kimia Farma ktk 60 tablet 670
368 Kuinin injeksi i.v. 25% (sebagai 2 HCl) n/a PT. Kimia Farma ktk 100 amp @ 2 ml 6,200.00
369 Kuinin tablet 222 mg (H2SO4.7H2O) n/a PT. Kimia Farma ktk 10 x 10 tablet 540
370 Lamivudin tablet/kaplet/kapsu 100 mg Heplav PT. Kimia Farma Botol 30 tab 2,000.00
371 Lamivudine tablet 150 mg n/a PT. Kimia Farma Botol 60 tablet 1,400.00
372 Lansoprazol inj 30 mg/ml Prosogan Inj. PT. Takeda Indonesia Serbuk vial 82,042.00
373 Lanzoprazol kapsul/kaplet 30 mg n/a PT. Indofarma Dus, 2 strip @ 10 kapsul 473
374 Lapatinib tab 250 mg Tykerb PT. SmithKline Dus, 7 Blister @ 10 tablet 67,200.00
Larutan mengandung Asam Amino (Asam
375 Amino 10%) Kalbamin PT. Finusolprima botol 500 ml 56,300.00
Larutan mengandung Asam Amino (Asam
376 Amino 100 g, Total N 15,7 g, Na+ 2 mEq, Asetat Amiparen PT Otsuka Indonesia Softbag 500 ML 56,300.00
120 mEq)

377 Larutan mengandung Asam Amino (Asam Pan-amin G PT Otsuka Indonesia Softbag 500 ML 37,500.00
Amino 27 g, Sorbitol 50 g, Cl- 52 mEq)
Larutan mengandung Asam Amino (Asam
378 Amino 30 g, Glukosa 7,3 % dan elektrolit) 1000 Aminofluid PT Otsuka Indonesia Double Chamber Softbag 1000 ML 115,500.00
ml
Larutan mengandung Asam Amino (Asam
379 Amino 30 g, Glukosa 7,3 % dan elektrolit) 500 Aminofluid PT Otsuka Indonesia Double Chamber Softbag 500 ML 61,600.00
ml
Larutan mengandung Asam Amino (Asam
380 Amino 5% dengan BCAA 45%, L-Ornithine L
Aspartate 8.03 gr/L, Sorbitol 50 gr/L, Xylitol 50 Aminofusin Hepar PT Kalbe Farma botol 500 mL 75,350.00
gr/L)
381 Larutan mengandung Asam Amino (Asam Aminosteril Infant 6% PT. Fresenius Botol Gelas 100 ml 36,667.00
Amino 6%, mengandung Taurine 0,24 gr/l)
Larutan mengandung Asam Amino (Asam
382 Amino 7%, Komposisi: Asam Amino esensial: Nephrosteril PT. Fresenius Botol Gelas 250 ml 50,820.00
Asam Amino non esensial = 60 : 40)
Larutan mengandung Asam Amino (Asam
383 Amino 72.05 g, Total N 11.53 g, AAE/AANE ratio Kidmin PT Otsuka Indonesia Softbag 200 ML 46,000.00
2.6, Na+ 2 mEq, Asetat 46 mEq)
Larutan mengandung Asam Amino (Asam
384 Amino 79.9 g, Total N 12.2 g, Na+ 14 mEq, Cl 94 Aminoleban PT Otsuka Indonesia Softbag 500 ML 65,000.00
mEq)
385 Larutan mengandung Asam Amino (Asam Aminosteril N-Hepa PT. Fresenius Botol Gelas 500 ml 78,720.00
amino 8%)
386 Larutan mengandung Asam Amino (Asam Eas Pfrimer PT. Finusolprima botol 250 ml 51,260.00
Amino esensial 7%+Xylitol 10 g/L)

Larutan mengandung Asam Amino (BCAA 25

387 gr/L, L-Ornithine L Aspartate 10 gr/L, Xylitol 50 Comafusin Hepar PT. Finusolprima botol 500 ml 64,900.00
gr/L, Malic Acid 7 gr/L, Piridoxin 0.12 gr/L)
Larutan mengandung Asam Amino (Kombinasi
Asam aminno 50 g/L, Sorbitol 50 g/L, Xylitol 50
388 g/L, Asam Askorbat (Vit C) 0.4 g/L, Inositol 0.5 Aminofusin L600 PT Kalbe Farma botol 500 mL 42,000.00
g/L, Nikotinamida (Niasinamida) 0.06 g/L,
Piridoksin HCl (Vit B6) 0.04 g/L, Riboflavin
Natrium Fosfat 2.5 mg/L, elektrolit)

389 Larutan mengandung Asam Amino (Kombinasi Aminofusin Paed PT Kalbe Farma botol 250 mL 46,000.00
Asam amino 50 g/L, vitamin dan elektrolit)
Larutan mengandung Asam Amino (Kombinasi
390 Asam Amino: 34gr, Glukosa: 97gr, Lipid: 51gr Kabiven 1440 ml PT. Fresenius Bag (3 Chamber) 1440 ml 295,240.00
dan Elektrolit (Kalori = 1000 kkal, Akses
peripheral))
Larutan mengandung Asam Amino (Kombinasi
391 Asam Amino: 45gr, Glukosa: 130gr, Lipid: 68gr Kabiven 1920 ml PT. Fresenius Bag (3 Chamber) 1920 ml 343,842.00
dan Elektrolit (Kalori = 1400 kkal, Akses
peripheral))
Larutan mengandung Asam Amino (Kombinasi
392 Glukosa dan elektrolit 150 gr + Asam Amino 48 Combiflex Plus (790 kcal) PT. Phapros, Tbk Bag Double chamber (Dua comparteme 322,000.00
gr dgn akses sentral)
Larutan mengandung Asam Amino (Kombinasi
393 Glukosa dan elektrolit 80 gr + Asam Amino 40 Combiflex peri (480 kcal) PT. Phapros, Tbk Bag Double chamber (Dua comparteme 218,700.00
gr )
394 Larutan mengandung Elektrolit (Kalium Klorida) Otsu - KCl 7,46% PT Otsuka Indonesia Ampoel 25 ML 2,050.00

395 Larutan mengandung Elektrolit (Larutan Ringer Wida RL PT. Widatra Bhakti Botol 1000 ml 8,000.00
Laktat)
396 Larutan mengandung Elektrolit (Na 130 mEq, Cl Asering PT Otsuka Indonesia Plastic Bottle 500 ML 9,000.00
109 mEq, Ca 3 mEq, Asetat 28 mEq)

397 Larutan mengandung Elektrolit (NaCl 1.125 gr, KA EN 1B PT Otsuka Indonesia Plastic Bottle 500 ML 9,000.00
Dekstrosa 18.75 gr)
Larutan mengandung Elektrolit (Sodium Lactate
398 sol (50%) 113 gr/L, Potassium Chloride 0.3 gr/L, Totilac PT Kalbe Farma flexybag 250 mL 87,000.00
Calcium Chloride 0.2 gr/L, elektrolit)
Larutan mengandung Elektrolit (Tiap 1000 ml
mengandung electrolit: Sodium 145 mmol/l,
399 Potassium 4.0 mmol/l, Calcium 2.5 mmol/l, Ringerfundin 500 mL PT. Phapros, Tbk LDPE (Low Density Poly Ethilene), botol 12,650.00
Magnesium 1.0 mmol/l, Chloride 118 mmol/l,
Acetate 24 mmol/l, Malate 5.0 mmol/l)

400 Larutan mengandung Karbohidrat (Fructose Triofusin 1000 PT Kalbe Farma botol 500 mL 50,500.00
120 g, glucose 66 g, Xylitol 60 g/ L + elektrolit)

401 Larutan mengandung Karbohidrat (Fructose 60 Triofusin 500 PT Kalbe Farma Flexy bag 500 mL 42,350.00
g, glucose 33 g, Xylitol 30 g/ L)

402 Larutan mengandung Karbohidrat (Maltose 100 Martos PT Otsuka Indonesia Plastic Bottle 500 ML 29,167.00
gr)
Larutan mengandung Karbohidrat + Elektrolit
403 (25.00g maltose, 3.00 g sodium chloride, 0.15 g Potacol inj PT Otsuka Indonesia Plastic Bottle 500 ML 55,500.00
potassium chloride, 0.10 g calcium chloride
dihydrate dan 1.55 g sodium lactate)

404 Larutan mengandung Karbohidrat + Elektrolit Tutofusin OPS PT Kalbe Farma botol 500 mL 37,500.00
(Acetate, Na, K, Cl, Ca, Mg, Sorbitol 50 gr/L)
Larutan mengandung Karbohidrat + Elektrolit
405 (Asam amino 28 gr/L, Glukosa 100 gr/L, Clinimix N9G20E PT Kalbe Farma Botol Plastik 1000 mL 210,000.00
elektrolit)
Larutan mengandung Karbohidrat + Elektrolit
406 (Asam amino 28 gr/L, Glukosa 75 gr/L, Clinimix N9G15E PT Kalbe Farma Botol Plastik 1000 mL 199,000.00
elektrolit)
407 Larutan mengandung Karbohidrat + Elektrolit Triofusin E1000 PT Kalbe Farma botol 500 mL 56,000.00
(Fructose 60 g, glucose 33 g, Xylitol 30 g/ L)
Larutan mengandung Karbohidrat + Elektrolit
408 (Glukosa 25 g, NaCl 2,0 g, KCl 1,3 g, Natrium Wida HSD PT. Widatra Bhakti Botol 500 ml 9,500.00
Laktat 3,1 g, air untuk injeksi ad 1000 ml)
Larutan mengandung Karbohidrat + Elektrolit
409 (Glukosa 55 g ; Natrium Chloride 9 g, air untuk Wida D5-NS PT. Widatra Bhakti Botol 500 ml 6,800.00
injeksi ad 1000 ml)
410 Larutan mengandung Karbohidrat + Elektrolit WIDA 2A PT. Widatra Bhakti Botol 500 ml 6,917.00
(Glukosa: 25,0 g; NaCl: 4,5 g)

411 Larutan mengandung Karbohidrat + Elektrolit WIDA D5-1/4NS PT. Widatra Bhakti Botol 500 ml 7,700.00
(Glukosa: 55.0 g; NaCl: 2.25 g)
412 Larutan mengandung Karbohidrat + Elektrolit WIDA D5-1/2NS PT. Widatra Bhakti Botol 500 ml 7,700.00
(Glukosa: 55.0 g; NaCl: 4.5 g)
Larutan mengandung Karbohidrat + Elektrolit
413 (Larutan nutrisi kombinasi infus per L: Na. Futrolit PT. Sanbe Farma softbag 500ml 35,750.00
100mEQ, K 18mEQ, Ca. 4mEQ, Mg 6mEQ, Cl
90mEQ, Asetat 38mEQ, Sorbitol 50g)
414 Larutan mengandung Karbohidrat + Elektrolit Wida RD PT. Widatra Bhakti Botol 500 ml 6,930.00
(Larutan Ringer & Glukosa 5%)

415 Larutan mengandung Karbohidrat + Elektrolit KA ENMG 3 PT Otsuka Indonesia Plastic Bottle 500 ML 9,167.00
(NaCl 1.75 g, KCL 1.5g, Glukosa 100 gr)
Larutan mengandung Karbohidrat + Elektrolit
416 (Nacl 1.75 gr, KCl 1.5 gr, Na Lactat 2.24 gr, KA EN 3B PT Otsuka Indonesia Plastic Bottle 500 ML 10,000.00
Dekstrosa 27 gr)
Larutan mengandung Karbohidrat + Elektrolit
417 (Nacl 2.34 gr, Na Laktat 2.24 gr, KCL 0.75 gr KA EN 3A PT Otsuka Indonesia Plastic Bottle 500 ML 10,000.00
Dekstrosa 27 gr)
418 Larutan mengandung Lipid ( Infus Lipid Emulsi Lipofundin MCT/LCT 1% 100 PT. Phapros, Tbk 20%, Botol Kaca @100 ml, single bottl 105,500.00
MCT/LCT 20% 100 ml)
419 Larutan mengandung Lipid (Emulsi lemak 20%) Intralipid PT. Fresenius Botol Gelas 100 ml 60,500.00
420 Larutan mengandung Lipid (Infus Lipid Emulsi Lipofundin MCT/LCT 1% 250 PT. Phapros, Tbk 20%, Botol Kaca @250 ml, single bottl 210,000.00
MCT/LCT 20% 250 ml)
Larutan mengandung Lipid (Kombinasi Glukosa
421 dan elektrolit 180 gr + Asam Amino 71.8 gr + Nutriflex Lipid Special 1250 PT. Phapros, Tbk Bag, 3 chamber ( 3 kompartemen), 12 591,000.00
Lipid 50 gr dgn akses sentral)
Larutan mengandung Lipid (Kombinasi Glukosa
422 dan elektrolit 80 gr + Asam Amino 40 gr + Lipid Nutriflex Lipid Peri 1250 PT. Phapros, Tbk Bag, 3 chamber ( 3 kompartemen), 12 511,000.00
MCT/LCT 50 gr)
Larutan mengandung Lipid (Kombinasi Glukosa
423 dan elektrolit 90 gr + Asam Amino 35.9 gr + Nutriflex Lipid Special 625 PT. Phapros, Tbk Bag, 3 chamber ( 3 kompartemen), 62 358,000.00
Lipid 25 gr dgn akses sentral)
Larutan mengandung Lipid (Soybean Oil 200
424 g/L, Egg Lecithins 12 gr/L, Glycerol Ph 25 gr/L, Ivelip PT Kalbe Farma Flexy bag 100 mL 89,800.00
Sodium Oleate 0.3 gr/L)
425 Latanoprost tetes mata 0,01% Cendo Glaopen PT. Cendo strip 5 x 0.6 ml 72,000.00
426 Latanoprost tts mata 0,005% btl@2,5ml Xalatan 0,005% PT. Pfizer Indonesia dus, Botol @ 2,5 ml 127,000.00
427 Lenograstim inj 263 mcg/mL Granocyte 34 1vl HSA Free PT. Aventis Pharma Dus, 1 vial @ 263 mcg + 1 prefilled sy 550,000.00
428 Letrozol tablet/kaplet/kapsul 2,5 mg FEMARA PT. Novartis Dus, 3 blister @ 10 tablet 17,500.00
429 Leuprorelin asetat inj depot 1,88 mg Tapros 1.88mg PT. Takeda Indonesia Vial 700,000.00
430 Leuprorelin asetat inj depot 11,25 mg Tapros 3M PT. Takeda Indonesia Vial 2,700,000.00
431 Leuprorelin asetat inj depot 3,75 mg TAPROS 3.75 MG PT. Takeda Indonesia Vial 500,000.00
432 Levofloksasin inf 5 mg/mL n/a PT. Infion Box, 1 Botol @ 100 ml 40,000.00
433 Levofloksasin tablet 500 mg n/a PT. Promedrahardjo Dus, 5 Strip@10 Tablet 528
434 Levofloksasin tts mata 0,5% Optiflox PT. Erela Btl @ 5 ml 13,068.00
435 Levotiroksin tablet/kaplet/kapsul 100 mcg Euthyrox 100 PT. Merck Tbk Dus 4 blister @ 25 tablet 850
436 Lidokain injeksi 2% (HCL) n/a PT. Bernofarm Dus, 100 ampul @ 2 ml 839
Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 -
437 2ml n/a PT. Indofarma Dus, 30 ampul @ 2 ml 1,363.00
438 Lidokain jeli 2% Xylocaine Jelly 2% PT. Astra Dus, 10 syringe @ 10 g 40,000.00
439 Lidokain semprot 10% Xylocaine Spray 10 mg/dosis PT. Astra Dus,Botol @ 50 ml (500 dosis) 142,000.00
440 Lisinopril tablet 10 mg n/a PT. Novell Box ,3 Strip @ 10 tablet 600
441 Lisinopril tablet 5 mg n/a PT. Novell Box ,3 Strip @ 10 tablet 350
442 Litium karbonat tablet 200 mg Frimania 200 PT. Mersifarma KOTAK @ 10 x 10 TAB 1,050.00
443 Litium karbonat tablet 400 mg Frimania 400 PT. Mersifarma KOTAK @ 10 x 10 TAB 1,850.00
444 Loperamid tablet 2 mg n/a PT. Ifars Dus, 10 Strip @ 10 Tablet 89
445 Loratadin tablet 10 mg n/a PT. Promedrahardjo Dus, 5 Strip@10 Tablet 154
446 Lorazepam tablet 0,5 mg MERLOPAM 0,5 mg PT. Mersifarma KOTAK @ 10 x 10 TAB 685
447 Lorazepam tablet 2 mg Merlopam 2 PT. Mersifarma KOTAK @ 10 x 10 TAB 1,341.00
448 Low molecule feri sucrose inj amp 100 mg/5 DIALIFER PT. Novell ampul 52,000.00
mL
449 Manitol n/a PT. Finusolprima botol 500 ml 62,000.00
450 Maprotilin HCl tab 25 mg Ludios PT. Soho Strip 1,200.00
451 Maprotilin HCl tab 50 mg Sandepril 50 PT. Mersifarma KOTAK @ 5 x 10 TAB 3,276.00
452 MDP (methylene diphosphonate) 1 mg Bonescan KaeF PT. Kimia Farma Dus @ 5 vial 473,000.00
methylene diphosphonic acid/mL
453 Mebendazol tablet 500 mg Vermox 500 PT. Taisho Dus,24 Catch @ 1 tablet 7,140.00
454 Medroksi Progesteron Asetat Provera 100mg PT. Pfizer Indonesia Dus, 10 blister @10 tablet 6,125.00
tablet/kaplet/kapsul 100 mg
455 Melfalan tablet 2 mg Alkeran PT. Glaxo Box, Tablet 2 mg/25's 12,210.00
456 Meropenem inj 1 g n/a PT. Bernofarm Dus, 1 vial @ 1 g 54,000.00
457 Meropenem serb inj 500 mg/vial n/a PT. Bernofarm Dus, 1 vial @ 0,5 g 44,960.00
458 Mesna inj 100 mg/mL Uromitexan injeksi. PT. Mugi Laboratories Dus, 15 Ampul 74,998.00
459 Metadon sir 50mg/5ml n/a PT. Kimia Farma Botol 1000 ml 254,100.00
460 Metformin HCl tablet 500 mg n/a PT. Bernofarm Dus, 10 blister @ 10 tablet 112.5
461 Metformin HCl tablet 850 mg n/a PT. Bernofarm Dus, 10 blister @ 10 kaptab 197.5
462 Metildopa tablet salut 250 mg DOPAMET PT. Actavis Dus, 10 Strip @ 10 tablet salut selaput 800
Metilergometrin Maleat (Metilergometrin)
463 tablet salut 0,125 mg n/a PT. Kimia Farma ktk 10 x 10 tablet salut 154
464 Metilergometrin Maleat injeksi 0,200 mg-1 ml n/a PT. Ethica ampul @ 1 ml 2,750.00
465 Metilfenidat kapsul LA 20 mg Ritalin LA PT. Novartis Dus, botol plastik @ 30 kapsul pelepa 6,537.00
466 Metilfenidat tablet SR 10 mg RITALIN PT. Novartis Dus, 2 blister @ 15 tablet 1,950.00
467 Metilprednisolon inj 125 mg/2 mL n/a PT. Dexa Medica Dus, 1 Vial @125mg + 1 ampul pelaru 19,200.00
468 Metilprednisolon inj 500 mg/8 mL n/a PT. Bernofarm Dus, 1 vial @ 500 mg 89,990.00
469 Metilprednisolon tablet 16 mg n/a PT. Mahakam Strip 635
470 Metilprednisolon tablet 4 mg n/a PT. Natura Dus, 10 Blister @ 10 Tablet 205
471 Metilprednisolon tablet 8 mg n/a PT. Dexa Medica Dus, 10 Blister @ 10 tablet 300
472 Metoklopramid drop botol 10 mL GAVISTAL drops PT. Meprofarm Dus, Botol 10 ml 5,280.00
473 Metoklopramide sirup 5 mg/ 5 ml LEXAPRAM SIRUP PT. Molex Ayus BOTOL 60 ML 2,600.00
474 Metoklopramide tablet 5 mg n/a PT. Kimia Farma ktk 10 x 10 tablet 108
475 Metotreksat serb inj 50 mg/2 mL Methotrexate Kalbe PT Kalbe Farma vial @ 2 ml 35,750.00
476 Metotreksat serbuk injeksi i.v/i.m./i.t. 5 mg METHOTREXATE EBEWE PT. Sandoz Box 10 ampul @ 1 ml 21,120.00
METHOTREXATE EBEWE 2.5
477 Metotreksat tablet/kaplet/kapsul 2,5 mg PT. Sandoz Box, bottle @ 50 tab 1,680.00
MG
478 Metronidazol infus 500 mg/100 ml n/a PT. Natura Dus, 1 Botol @ 100 ml 9,950.00
479 Metronidazol ovula 500 mg Vagizol PT. Kimia Farma dus 1 's @ 5 ovula 3,850.00
480 Metronidazol supositoria 500 mg Flagyl PT. Aventis Pharma Dus, 2 blister @ 5 suppositoria 3,220.00
481 Metronidazol tablet 250 mg n/a PT. Phyto 10 strip @ 10 tab 110
482 Metronidazol tablet 500 mg n/a PT. Phyto 10 strip @ 10 tab 160
483 MIBG (meta-iodobenzylguanidine) Endoneuroscan KaeF 1 PT. Kimia Farma vial 1,925,000.00
MIBI (metoxy iso butyl iso nitril) 5-mL reaction
484 vial Cardioscan KaeF PT. Kimia Farma Dus @ 5 vial 1,237,500.00
485 Midazolam injeksi i.v. 1 mg/ml Fortanest PT Kalbe Farma Box isi 5 ampul 6,000.00
486 Midazolam injeksi i.v. 5 mg/ml Dormicum PT. Boehringer Boks 5 amp 12,060.00
487 Mikafungin Na serb inj 50 mg Mycamine PT. Combiphar Dus,1 vial@50mg 260,000.00
488 Mikofenolat Mofetil 500 mg Cellcept PT. Boehringer Boks, 50 tablet 16,000.00
489 Mikonazol krim/salep 2 % (Nitrat) n/a PT. Kimia Farma Tube 10 gram 3,000.00
490 Mitomisin C (crystallin) serbuk inj 10 mg/vial Mitomycin C PT. Widatra Bhakti 10 mg /Vial 697,000.00
491 Modified fluid gelatine BM 30 000 lar inf 4% Gelofusine 4% PT. Phapros, Tbk Btl @ 500 ml 72,000.00
492 Moksifloksasin tetes mata 0,5% Vigamox PT. Tempo botol, tetes mata 3 ml 77,000.00
493 Mometason furoat krim 0,1% n/a PT. Guardian tube 10 gram 17,820.00
494 Morfin HCL inj 10 mg/ml n/a PT. Kimia Farma Dus 10 amp @ 1 ml 8,400.00
495 Morfin HCL tablet SR 10 mg MST Continus 10 mg PT. Mahakam Dus, 6 strip @ 10 tablet 15,620.00
496 Morfin HCL tablet SR 15 mg MST Continus 15 mg PT. Mahakam Dus, 6 strip @ 10 tablet 22,990.00
497 Morfin tablet 10 mg n/a PT. Kimia Farma Botol 30 tablet 1,300.00
498 N-asetil sistein inj. nebules 100 mg N-ace cairan inhalasi PT. Pratapa Nirmala Box @ 5 ampul 13,200.00
499 Nacl 0,9% n/a PT. Widatra Bhakti Botol 500 ml 4,700.00
500 Nadroparin inj 9500 Axa/mL syringe 0,3 mL Fraxiparine 0.3 ml PT. Glaxo Dus, 5 blister @ 2 pfs 0.3 ml 54,144.00
501 Nadroparin inj 9500 Axa/mL, syringe 0,4 mL Fraxiparine 0.4 ml PT. Glaxo Dus, 5 blister @ 2 pfs 0.4 ml 66,640.00
502 Nadroparin inj 9500 Axa/mL, syringe 0,6 mL Fraxiparine 0.6 ml PT. Glaxo Dus, 5 blister @ 2 pfs 0.6 ml 94,962.00
503 Nalokson injeksi 0,4 mg/ml Nokoba PT. Pratapa Nirmala Dus, 5 Ampul @ 2ml 61,600.00
504 Natrium Bikarbonat injeksi i.v 8,4% Meylon PT Otsuka Indonesia Ampoel 25 ML 6,200.00
505 Natrium Diklofenak tablet 50 mg n/a PT. Phapros, Tbk Dus @ 5 X 10 's 176
506 Natrium Diklofenak tablet 25 mg n/a PT. Phapros, Tbk Dus @ 5 X 10 's 133
507 Natrium fosfat lar oral 45 mL Fleet Phosphosoda PT. Combiphar Botol, 45 ml 33,900.00
508 Natrium fusidat salep 20 mg/g Fucilex Ointment PT. Molex Ayus Tube 5 gr 6,490.00
509 Neostigmin injeksi 0,5 mg/ml Neostigmin Hameln inj PT. Pharma Health Care Box, isi 5 ampul @ 1 ml 9,500.00
510 Nevirapin tablet 200 mg n/a PT. Kimia Farma btl 60 tablet 2,800.00
511 Nifedipin tab 20 mg, slow release; oros Adalat Oros 20 mg PT. Bayer Indonesia blister 2,999.00
512 Nifedipin tab 30 mg, oros Adalat Oros 30 mg PT. Bayer Indonesia blister 3,500.00
513 Nifedipin tablet/kapsul 10 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet salut selaput 110
Nilotinib kapsul 200 mg (Skema Risk Sharing
514 sesuai Kepmenkes RI Nomor Tasigna PT. Novartis Dus, 2 blister @ 14 kapsul 380,875.00
HK.02.02/Menkes/223/2014)
515 Nistatin tablet salut 500.000 IU/ g n/a PT. Phapros, Tbk Dus @ 10 X 10 's 640
516 Nistatin vaginal tablet 100.000 IU/ g n/a PT. Phapros, Tbk Dus @ 10 X 10 's 480
517 Norepinefrin injeksi 1 mg/ml Levosol PT. Kimia Farma Dus 5 amp @ 8 ml 53,900.00
518 Noretisteron tablet 5 mg Primolut N PT. Bayer Indonesia blister 2,618.00
519 Obat Antituberkulosis FDC Kategori 1 n/a PT. Kimia Farma Paket 359,990.00
520 Obat Antituberkulosis FDC Kategori 2 n/a PT. Indofarma Paket 1,199,990.00
521 Obat Antituberkulosis FDC Kategori Anak n/a PT. Phapros, Tbk Paket 214,900.00
522 Obat Antituberkulosis FDC Sisipan n/a PT. Indofarma Paket@84 tablet 160,000.00
523 Obat Antituberkulosis Kategori 1 dewasa n/a PT. Indofarma Dus, 1 dus @ 60 blister @ 8 tablet taha 288,199.00
524 Obat Antituberkulosis Kategori anak n/a PT. Indofarma Dus, 60 sachet tahap intensif @ (1 tabl 171,195.00
525 Octreotide Acetate0,05 - 6 mg/mL Octide PT. Pratapa Nirmala Box @ 5 ampul 80,000.00
526 Ofloksasin tets telinga 3% Tarivid Otic Solution PT Kalbe Farma Btl @ 5 ml 48,500.00
527 Ofloxacin tablet 200 mg n/a PT. Novell Box ,5 Strip @ 10 tablet 400
528 Ofloxacin tablet 400 mg n/a PT. Novell Box ,5 Strip @ 10 tablet 650
529 Oksaliplatin serbuk injeksi 100 mg / vial ELOXATIN PT. Aventis Pharma Dus, 1 vial @ 20 ml 1,100,000.00
530 Oksaliplatin serbuk injeksi 50 mg / vial ELOXATIN PT. Aventis Pharma Dus, 1 vial @ 10 ml 550,000.00
531 Oksimetazolin tetes hidung 0,025% Ilaidin Drops PT. Merck Tbk botol @ 10 ml 27,550.00
532 Oksitosin injeksi 10 IU/ml Oxytocin "S" PT. Ethica ampul @ 1 ml 2,200.00
533 Oktreotid 10 mg Sandostatin LAR PT. Novartis Dus, vial @ 355m + 1 prefilled syringe 2,950,000.00
534 Olanzapin inj 10 mg/vial Zyprexa IM PT. Bayer Indonesia Vial 120,000.00
535 Olanzapin kapl salut 5 mg Olandoz 5 PT. Sandoz 3 X 10 fcc 6,450.00
536 Olanzapin tab 10 mg Olandoz 10 PT. Sandoz 3 X 10 fcc 11,200.00
537 Olopatadin tts mata 0,1% Patanol PT. Tempo botol, tetes mata 5 ml 68,000.00
538 Omeprazol injeksi 40 mg/ 10 ml n/a PT. Natura Dus, 1 Vial @ 40 mg 36,000.00
539 Omeprazol kapsul/kaplet 20 mg n/a PT. Novapharin dus 10 X 3'S 211
540 ondansetron inj 4 mg/ 2 mL n/a PT. Indofarma Dus, 5 Ampul @ 2ml 2,400.00
541 Ondansetron tab 4 mg n/a PT. Yarindo Box 3 X 10 Tab 716
542 Ondansetron tablet 8 mg n/a PT. Yarindo Box 3 X 10 Tab 1,189.00
Paket CAPD Awal (Komposisi: 1 unit Transfer
543 Set, 2 unit Ultaclam, 1 unit Tenckoff Catheter, n/a PT Kalbe Farma Transfer Set: Set; Ultaclam: Kantong Pl 1,902,240.00
Titanium Adaptor) Larutan Dialisa 1.5%: Dianeal
544 Paket CAPD Pergantian Transfer Set per 6 bulan n/a
Low Calcium with 1,5% PT Kalbe Farma Set 219,540.00
Paket CAPD Rutin 120 ( 4x ganti cairan perhari Dextrose; Larutan Dialisa 2.5%:
545 dengan komposisi Larutan Dialisa 1.5 %, Dianeal Low Calcium with 2,5% PT Kalbe Farma Larutan Dialisa 1.5 %: 2.000 ml; Laruta 5,522,580.00
Larutan Dialisa 2.5 %, Larutan Dialisa 4.25 %, Dextrose; Larutan Dialisa
Minicap)
546 Paklitaksel inj 100 mg/vial 4.25%: Dianeal
SINDAXEL Low Calcium
100 MG/16,67 ML PT. Actavis Vial 6mg/ml (100mg/16.67ml) 984,000.00
with 4.25% Dextrose
547 Paklitaksel inj 300 mg/vial SINDAXEL 260mg/43.33 ML PT. Actavis Vial 6mg/ml (260mg/43.33ml) 3,000,000.00
548 Paklitaksel injeksi 30 mg/vial SINDAXEL 30 MG/5 ML PT. Actavis Vial 6mg/ml (30mg/5ml) 274,560.00
549 Parasetamol drop 100 mg/ml btl @15ml n/a PT. Indofarma Dus, 15 botol 5,200.00
(60mg/0,6ml)
550 Parasetamol sirup 120 mg / 5 ml n/a PT. Afifarma botol 60 ml 1,438.00
551 Parasetamol tablet 500 mg n/a PT. Promedrahardjo Dus, 10 Strip@10 Kaplet Salut Selaput 79
552 Parasetamol tetes 60 mg/0,6 mL NAPREX DROPS PT. Darya Varia botol @ 15 ml 6,730.00
553 Pegylated interferon alfa-2a inj 135 mcg/0,5 ml Pegasys PT. Boehringer Boks, 1 pfs 1,077,815.00
554 Pegylated interferon alfa-2a inj 180 mcg/0,5 ml Pegasys PT. Boehringer Boks, 1 pfs 1,248,220.00
555 Pegylated Interferon alfa-2b serb inj 100 mcg Pegintron Vial 100 Mcg PT. Merck Dus, 1 vial 100 mcg + 1 ampul pelarut 973,500.00
556 Pegylated Interferon alfa-2b serb inj 120 mcg Pegintron Pen 120 Mcg PT. Merck Dus, 1 prefilled syringe (serbuk injeks 1,135,000.00
557 Pegylated Interferon alfa-2b serb inj 50 mcg Pegintron PT. Merck Dus, 1 vial 50 mcg + 1 ampul pelarut 0, 915,000.00
558 Pegylated Interferon alfa-2b serb inj 80 mcg Pegintron Vial 80 Mcg PT. Merck Dus, 1 vial 80 mcg + 1 ampul pelarut 0, 915,810.00
559 Perak sulfadiazin krim 1% BURNAZIN 35 GR PT. Darya Varia tube @ 35 gram 23,000.00
560 Perindoprilarginin tab 5 mg Bioprexum 5 mg PT. Pradja Pharin Dus, botol plastik @ 30 tablet salut se 2,420.00
561 Permetrin krim 5% Scabimite Cream 10 PT. Galenium Tube @ 10 g 11,475.00
562 Petidin injeksi i.m/s.k/i.v lambat 50 mg/ml (HCl) n/a PT. Kimia Farma Ktk 10 ampx2ml 14,500.00
563 Pioglitazon tab 15 mg DECULIN 15 MG PT. Dexa Medica 30 TAB/BOX 3,120.00
564 Pioglitazon tab 30 mg DECULIN 30 MG PT. Dexa Medica 30 TAB/BOX 4,525.00
565 Pirantel suspensi 125 mg/5 ml n/a PT. Holi Pharma Botol 60 ml 8,360.00
566 Pirantel tablet score (base) 125 mg n/a PT. Holi Pharma Dus, 25 Blister @ 4 tablet 298
567 Pirazinamid tablet 500 mg n/a PT. Holi Pharma Dus 10 strip @ 10 tablet 208
568 Piridoksin (vitamin B6) inj 100 mg/mL n/a PT. Ikapharmindo Ampul 1 ml 1,000.00
569 Polikresulen cairan Aptil PT. Pratapa Nirmala Dus, Botol @ 10ml 17,393.00
570 Povidon Iodida larutan 10% 1000 ml n/a PT. Afifarma botol @ 1000 ml 37,109.00
571 Povidon Iodida larutan 10% 30 ml n/a PT. Afifarma botol @ 30 ml 2,163.00
572 Povidon Iodida larutan 10% 300 ml n/a PT. Afifarma botol @ 300 ml 14,203.00
573 Povidon Iodida larutan 10% 60 ml n/a PT. Kimia Farma btl 60 ml 5,998.00
574 Pramipeksol tab ER 0,375 mg Sifrol ER 0,375mg PT. Boehringer Dus, 3 alu blister @ 10 tablet 7,200.00
575 Pramipeksol tab ER 0,750 mg Sifrol ER 0,750mg PT. Boehringer Dus, 3 alu blister @ 10 tablet 11,268.00
576 Pravastatin tablet 20 mg n/a PT. Novell Box ,5 Strip @ 10 tablet 2,300.00
577 Prednison tablet/kapsul/kaplet 5 mg n/a PT. Holi Pharma Dus, 10 strip @ 10 tablet 114
578 Probenesid tablet/kapsul/kaplet 500 mg Probenid PT. Dexa Medica Dus, 10 strip @ 10 tablet 1,650.00
579 Prokain Benzilpenisilin serbuk injeksi 3 juta n/a PT. Bernofarm Vial @ 3 juta IU 7,190.00
IU/vial
580 Propanolol tablet 10 mg ( HCl ) n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 65
581 Propiltiourasil tablet/kapsul/kaplet 100 mg n/a PT. Indofarma Botol @ 100 Tablet 319
582 Propofol injeksi i.v., bolus 1% Fresofol 1% MCT/LCT PT. Fresenius Ampul 15,642.00
583 Propranolol tablet 40 mg (HCl) n/a PT. Holi Pharma Dus, 10 strip @ 10 tablet 107
584 Quetiapin tab 200 mg Seroquel XR 200 mg PT. Astra Dus, 1 blister @ 10 tablet 17,391.00
585 Quetiapin tab 300 mg Seroquel XR 300 mg PT. Astra Dus, 1 blister @ 10 tablet 19,500.00
586 Quetiapin tab 400 mg Seroquel XR 400 mg PT. Astra Dus, 1 blister @ 10 tablet 23,185.00
587 Ramipril tablet 2,5 mg Cardace 2.5mg 6x10 s tablet PT. Pharma Health Care Dus, 6 blister @ 10 tablet 995
588 Ramipril tablet 5 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 kaptab 580
589 Ramipril tablet/kaplet/kapsul 10 mg n/a PT. Novell Dus, 10 strip @ 10 tablet 1,013.00
590 Ranitidin injeksi 25 mg/ml n/a PT. Natura Dus, 10 Ampul @ 2 ml 1,140.00
591 Ranitidin tablet 150 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet salut selaput 120
592 Retinol (Vitamin A) 100.000 IU n/a PT. Kimia Farma Botol 50 kapsul lunak 260
593 Retinol (Vitamin A) 200.000 IU kapsul lunak n/a PT. Kimia Farma Botol 50 Kapsul 459
594 Rifampisin tablet/kapsul/kaplet 300 mg n/a PT. Indofarma Dus, 10 Strip @ 10 Kapsul 609
595 Ringer Laktat larutan infus n/a PT. Widatra Bhakti botol 500 ml 5,200.00
596 Risperidon tablet 1 mg n/a PT. Dexa Medica Dus, 5 Blister @ 10 tablet 1,200.00
597 Risperidon tablet 2 mg n/a PT. Mersifarma KOTAK @ 5 x 10 TAB 1,008.00
598 Risperidon tablet 3 mg n/a PT. Dexa Medica Dus, 5 Blister @ 10 tablet 2,000.00
Rituksimab injeksi 10 mg/ml (Skema Risk
599 Sharing sesuai Kepmenkes RI Nomor Mabthera PT. Boehringer Dus, 1 vial @ 10 ml 3,164,805.00
HK.02.02/Menkes/223/2014)
600 Rivaroksaban tab 10 mg Xarelto 10 mg PT. Bayer Indonesia Blister 23,500.00
601 Rivaroksaban tab 15 mg Xarelto 15 mg PT. Bayer Indonesia Blister 23,500.00
602 Rivaroksaban tab 20 mg Xarelto 20 mg PT. Bayer Indonesia Blister 23,500.00
603 Ropinirol Tablet Salut 2 mg Requip PD 24 Hour 2 mg PT. Glaxo Dus, 7 blister @ 4 Tablet lepas Lambat 5,248.00
604 Ropinirol Tablet Salut 4 mg Requip PD 24 Hour 4 mg PT. Glaxo Dus, 7 blister @ 4 Tablet lepas Lambat 6,275.00
605 Ropinirol Tablet Salut 8 mg Requip PD 24 Hour 8 mg PT. Glaxo Dus, 7 blister @ 4 Tablet lepas Lambat 7,383.00
606 Salbutamol cairan ih 0,1% Ventolin Nebules PT. Glaxo Dus, 4x5 Botol Plastik@2.5 ml 6,600.00
607 Salbutamol inhalasi/aerosol 100 mcg/dosis Ventolin Inhaler PT. Glaxo Dus, botol 200 dosis 63,750.00
608 Salbutamol serb inh 200 mcg/kaps Ventolin Rotacaps PT. Glaxo Dus, 10 Blister @ 10 Kapsul 431
609 Salbutamol serb inh 200 mcg/kaps + rotahaler Ventolin Rotahaler PT. Glaxo Dus, 1 Rotahaler 5,867.00
610 Salbutamol tablet 2 mg (sebagai Sulfat) n/a PT. Yarindo strip @ 10 tablet 59
611 Salbutamol tablet 4 mg (sebagai Sulfat) n/a PT. Kimia Farma ktk 10 x 10 tablet 89
612 Salep 2-4 , Kombinasi : Asam Salisilat 2% + n/a PT. Marin Liza Farmasi Pot @ 30 gram 2,000.00
Belerang endap 4%
613 Sefadroksil sirup kering 125 mg/5ml n/a PT. Holi Pharma Dus, Botol 60 ml 4,896.00
614 Sefadroksil kapsul/kaplet 250 mg n/a PT. Hexpharm strip 513
615 Sefadroksil kapsul/kaplet 500 mg n/a PT. Bernofarm Dus, 10 strip @ 10 kapsul 509
616 Sefadroksil sir kering 250 mg/5 mL n/a PT. Holi Pharma Dus, Botol 60 ml 5,940.00
617 Sefaleksin kapsul/kaplet 500 mg n/a PT. Ifars Dus, 5 Strip @ 10 Kapsul 1,000.00
618 Sefazolin serbuk injeksi 1 g/vial n/a PT. Dexa Medica Dus, 2 Vial @ 1 gram 16,500.00
619 Sefepim inj 1 g n/a PT. Yarindo Box 2 Vial @ 1000mg 48,060.00
620 Sefiksim kapsul/kaplet 100 mg n/a PT. Bernofarm Dus, 10 blister @ 10 kapsul 859
621 Sefiksim sirup kering 100 mg/ 5 ml n/a PT. Ifars Dus, Botol 30 ml 8,800.00
622 Sefoperazon inj 1 g n/a PT. Holi Pharma Dus, 2 vial @ 1 g 12,775.00
623 Sefotaksim injeksi 0,5 g n/a PT. Hexpharm vial 4,800.00
624 Sefotaksim injeksi 1 g n/a PT. Natura Dus, 10 Vial @ 1 g 2,950.00
625 Sefpodoksim proksetil tab 100 mg Banadoz 100 PT. Sandoz Dus, 3 blister @ 10 tablet 3,700.00
626 Seftazidim injeksi 1 g n/a PT. Dexa Medica Dus, 2 Vial @ 1 gram 16,000.00
627 Seftriakson serbuk injeksi 1 g/vial n/a PT. Natura Dus, 10 Vial @ 1 g 3,300.00
628 Sefuroksim tablet/kapsul/kaplet 250 mg Zinnat 250 mg PT. Glaxo Dus, 1 Blister @ 10 Tablet salut selapu 4,752.00
629 Sefuroksim tab 500 mg Zinnat 500 PT. Glaxo Dus, 1 Blister @ 10 Tablet salut selapu 7,200.00
630 Sertralin tab 50 mg Fatral PT. Pratapa Nirmala strip @ 10 tab 3,300.00
631 Setirizin sirup 5 mg/5 ml n/a PT. Indofarma Botol @ 60 ml 7,999.00
632 Setirizin tablet 10 mg n/a PT. Pertiwi Agung Box, 10 strips @ 10 capsules 181
Setuksimab infus 5 mg/ml (Skema Risk Sharing
633 sesuai Kepmenkes RI Nomor Erbitux PT. Merck Tbk Dus, 1 vial @ 20 ml 3,650,000.00
HK.02.02/Menkes/223/2014)
634 Sevofluran ih, btl Sojourn PT. Pratapa Nirmala tabung/botol 1,320,000.00
635 Sianokobalamin (vitamin B12) injeksi 500 mcg n/a PT. Lucas Djaja 100 ampul @ 1 ml 1,078.00
636 Sianokobalamin (vitamin B12) n/a PT. Afifarma Dus, 10 Strip @ 10 tablet 57
tablet/kapsul/kaplet 50 mcg
637 Siklofosfamid serbuk injeksi i.v. 1000 mg Cyclovid 1000 mg PT. Novell vial 256,000.00
638 Siklofosfamid serbuk injeksi i.v. 200 mg Cyclovid 200 mg PT. Novell vial 82,000.00
639 Siklofosfamid serbuk injeksi i.v. 500 mg CYCLOVID 500 PT. Novell Vial 120,000.00
640 Siklosporin kaps 100 mg Sandimmun Neoral 100mg Kap PT. Novartis Dus, 10 blister @ 5 kapsul lunak 43,000.00
641 Siklosporin kapsul lunak 25 mg Sandimmun Neoral 25mg Kap PT. Novartis Dus, 10 blister @ 5 kapsul lunak 12,000.00
642 Simvastatin scored tablet 10 mg n/a PT. Natura Dus, 3 Strip @ 10 Kaplet salut selaput 169
643 Simvastatin tablet 20 mg n/a PT. Natura Dus, 3 Strip @ 10 Kaplet salut selaput 391
644 Siprofloksasin infus 2% n/a PT. Dexa Medica Vial 200 ml 13,000.00
645 Siprofloksasin tablet 500 mg (sebagai HCl) n/a PT. Bernofarm Dus, 10 blister @ 10 tab ss 255
646 Sisplatin serbuk injeksi 10 mg Cisplatin PT Kalbe Farma vial 22,000.00
647 Sisplatin serbuk injeksi 50 mg Cisplatin PT Kalbe Farma vial 93,000.00
648 Sitarabin serbuk injeksi i.m./i.v./s.k. 1gr/10ml DBL Cytarabun PT. Tempo dus, 1 vial @ 10 ml 575,000.00
649 Spiramisin tablet 500 mg n/a PT. Indofarma Dus, 5 strip @ 10 tablet 1,499.00
650 Spironolakton tablet 100 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 900
651 Spironolakton tablet 25 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 315
652 Stavudin tablet/kapsul/kaplet 30 mg n/a PT. Kimia Farma Botol @ 60 tablet 930
653 Streptokinase injeksi 1,5 juta UI/vial Streptase PT. Dexa Medica Vial 3,290,000.00
654 Streptomisin serbuk injeksi i.v 1000 mg/ml n/a PT. Phapros, Tbk Dus @ 56 Vial 3,650.00
Sufentanyl Injeksi iv.Epidural 5 PT. Kimia Farma
655 Sufentanil injeksi iv, epidural 5 mcg/ml dus 5 amp @ dus 10 127,000.00
mcg / ml
656 Sukralfat susp 500 mg/5 mL Ulsafate PT. Combiphar Botol, 100 ml 13,425.00
657 Sukralfat tab 500 mg ULSIDEX PT. Dexa Medica DUS, 10 STRIP @ 10 TAB 424
658 Takrolimus kaps 0.5 mg Prograf PT. Combiphar Pounch @ 5 blister @ 10 capsule 11,167.00
659 Takrolimus kaps 1 mg Prograf PT. Combiphar Dus, 1 pouch @5 blister@10 kaps 21,500.00
660 Tamsulosin tab 0,2 mg Harnal ® D 0.2 mg Disp. Tablet PT. Combiphar Box/ 2 blister @ 14 tablet 5,800.00
661 Tamsulosin tab 0,2 mg Harnal D PT. Combiphar Box @ 2 blister @ 14 tablet 5,800.00
662 Tamsulosin tab SR 0,4 mg Harnal ® OCAS 0.4 mg Tablet PT. Combiphar Box/ 3 blister @ 10 Tablet 6,800.00
663 Telbivudin tab 600 mg Sebivo 600 mg Tab PT. Novartis Dus, 2 blister @ 14 tablet 28,500.00
664 Telmisartan tab 40mg Micardis 40mg PT. Boehringer Dus, 2 alu-blister @10 tablet 3,900.00
665 Telmisartan tab 80 mg Micardis 80mg PT. Boehringer Box, 2 blisters @10 tablets 6,500.00
666 Temozolamid kaps 100 mg Temodal PT. Merck Dus, 5 sachet @ 1 kapsul 1,120,000.00
667 Temozolamid kaps 20 mg Temodal PT. Merck Dus, 5 sachet @ 1 kapsul 223,000.00
668 Tenofovir tab 300 mg n/a PT. Kimia Farma Botol 30 tab 8,100.00
669 Teofilin tab SR 300 mg Rethapyl PT. Kimia Farma Dus 10-s @ 10 Kaptab 1,050.00
670 Teofilin tablet 150 mg Bronsolvan PT Kalbe Farma strip 250
671 Terazosin HCl tablet/kapsul/kaplet 1 mg HYTROZ 1MG PT. Dexa Medica DUS, 10 BLISTER @ 10 TAB 1,669.00
672 Terazosin HCl tablet/kapsul/kaplet 2 mg HYTROZ 3MG PT. Dexa Medica DUS, 10 BLISTER @ 10 TAB 2,949.00
673 Terbutalin cairan ih 2,5 mg/mL Bricasma Respules PT. Astra Dus, 2 pak @ 5 respules 6,250.00
674 Terbutalin tablet 2,5 mg Molasma Tablet PT. Molex Ayus Box 50's 99
675 Terbutalin turbu (serbuk ih) 0,50 mg Bricasma Turbuhaler 0,5 mg PT. Astra Dus, 1 Turbuhaler @ 200 dosis 71,100.00
676 Testoteron soft capsul 40 mg Andriol Testocaps PT. Merck Dus, 6 blister @ 10 kapsul lunak 6,200.00
677 Tetrakain HCl tetes mata 0,5% Pantocain 0.5% PT. Cendo botol 5 ml 11,500.00
678 Tetrasiklin kapsul/kaplet 250 mg n/a PT. Holi Pharma Dus, 10 strip @ 10 kapsul 149
679 Tetrasiklin tablet/kapsul/kaplet 500 mg n/a PT. Afifarma DUS,10 STRIP @ 10 KAPSUL 300
680 Tiamazol tab 10 mg Thyrozol 10 PT. Merck Tbk Dus, 10 blister @ 10 tablet 1,135.00
681 Tiamazol tab 5 mg Thyrozol 5 PT. Merck Tbk Dus, 10 blister @ 10 tablet 563
682 Timolol tetes mata 0,25% Isotic Adretor 0,25% PT. Pratapa Nirmala Dus, Botol Plastik @ 5ml 9,128.00
683 Timolol tetes mata 0,5% Isotic Adretor 0,5% PT. Pratapa Nirmala Dus, Botol Plastik @ 5ml 9,722.00
Spiriva powder for inhalation
684 Tiotropium 18 mcg refill PT. Boehringer Box, 3 blisters @10 capsules 13,867.27
18mcg 30s
685 Tiotropium kaps 18 mcg + handihaller Spiriva 10s + Handihaler PT. Boehringer Dus, 1 blister @10 kapsul + handihaler 152,543.00
686 Tramadol injeksi 50 mg/ml n/a PT. Natura Dus, 10 Ampul @ 2 ml 2,395.00
Trastuzumab serbuk injeksi 440 mg/vial (Skema
687 Risk Sharing sesuai Kepmenkes RI Nomor Herceptin PT. Boehringer Dus, 1 vial @ 440 mg + 1 vial pelarut 19,608,034.00
HK.02.02/Menkes/223/2014)
688 Travoprost tetes mata 0,004% Travatan PT. Tempo botol, tetes mata 2,5 ml 115,000.00
689 Triamsinolon asetonid nasal spray 55 mcg/puff Nasacort AQ PT. Aventis Pharma Dus, botol plastik 120 dosis 90,000.00
690 Trifluoperazin tablet 5 mg n/a PT. Darya Varia strip 405
691 Tropikamid tetes mata 1% Cendo Mydriatil 1% PT. Cendo Botol 5ml 36,500.00
692 Urea krim 10% Soft U Derm PT. Galenium tube 6,400.00
693 Vaksin polio inj (Vaksin Poliomyelitis yang Imovax Polio PT. Aventis Pharma 1 vial of 10ml (10 d's) 285,000.00
diinaktifkan)
694 Vaksin rabies, untuk manusia serbuk injeksi RABIPUR PT. Novartis Dus, 1 vial serbuk + 1 ampul @ 1 ml pe 78,500.00
s.k./i.k. + booster
695 Valgansiklovir tab 450 mg Valcyte PT. Boehringer Boks, 60 tablet 170,000.00
696 Valproat sirup 250 mg/5 ml Ikalep PT. Ikapharmindo Botol 120 ml 40,000.00
697 Valproat tab SR 250 mg Depakote ER 250 mg PT. Abbott Indonesia Tablet 2,793.00
698 Valproat tab SR 500 mg Depakote ER 500 mg PT. Abbott Indonesia Tablet 5,450.00
699 Valproat tablet salut 250 mg Depakote Tab 250 mg PT. Abbott Indonesia Tablet salut 250 mg 1,680.00
700 Valsartan tab 80 mg Diovan 80mg Tab PT. Novartis DUS, 3 ALU-ALU STRIP @ 10 tablet salu 3,900.00
701 Valsartan tab 160 mg DIOVAN 160 MG PT. Novartis DUS, 3 ALU-ALU STRIP @ 10 tablet salu 6,500.00
702 Vankomisin serbuk injeksi 500 mg/vial Vancep PT. Pratapa Nirmala Box @ 2 vial 122,000.00
703 Verapamil tab 240 mg Isoptin 240 mg PT. Abbott Indonesia Tablet 6,200.00
704 Verapamil tablet 80 mg (HCl) n/a PT. Kimia Farma Ktk 10X10 TAB 234
705 Vinblastin serbuk injeksi 10 mg Vinblastine PT. Combiphar Vial 10mg/10ml 210,000.00
706 Vinkristin serb inj i.v 2 mg/vial Vincristine Kalbe PT Kalbe Farma vial @ 2 ml 78,000.00
707 Vinkristin serbuk injeksi i.v. 1 mg Vincristine Kalbe PT Kalbe Farma vial @ 1 ml 46,000.00
708 Vinorelbin inj. 10 mg/ml Navelbine injeksi 10 PT. Mugi Laboratories Dus, 1 vial @ 1 ml 1,229,998.00
709 Vitamin B Kompleks tablet n/a PT. Kimia Farma Dus 10 strip x 10 tab 107
710 Zidofudin 100 mg n/a PT. Kimia Farma Botol 60 Kapsul 1,575.00
711 Zidovudin 300 mg + Lamivudine 150 mg n/a PT. Kimia Farma Botol 60 tablet 3,429.00
712 Zinc drop 10 mg/mL Zincpro Drops PT. Combiphar Drops 10 mg/ml, Botol @15 ml 12,840.00
713 Zinc sir 20 mg/5 Ml Zircum Kid Sirup PT. Meprofarm Dus, botol 60 ml 7,400.00
714 Zinc tablet dispersible20 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet dispersible 474