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DAFTAR USULAN OBAT BPJS

HARGA SATUAN JLH PERMINTAAN


No NAMA OBAT KEMASAN JLH SELAMA 1 TAHUN KET
TERKECIL BULANAN
1 Albendazol tablet/kapsul /kaplet 400 mg ktk 5 x 6 tablet 350.00 1000 12000
2 Alopurinol tablet /kapsul /kaplet 300 mg Dus , 10 blister @ 10 tablet 219.50 1500 18000
3 Alprazolam tablet /kapsul /kaplet 1 mg ktk 10 x 10 tablet 233.00 1000 12000
4 Aminofilin tablet scored 200 mg Botol @ 100 tablet 82.00 1500 18000
5 Amlodipin tablet 10 mg Box , 3 strips @ 10 tablets 341.00 1500 18000
6 Amoksisilin kapsul /kaplet /tablet scored 500 mg KOTAK @ 10 x 10 TAB 10000 120000
7 Amoksisilin sirup kering 125 mg /5 ml Btl @ 60 ml 180 2160
8 Antasida DOEN I tablet kunyah ,
kombinasi : Aluminium Hidroksida 200 mg Magnesium Dus , 10 strip @ 10 tablet 10000 120000
9 Hidroksida 200 mg
10 Antasida DOEN II suspensi ,
kombinasi : Aluminium Hidroksida 200 mg/5ml btl 60 ml 180 2160
11 Magnesium Hidroksida 200 mg/ml

12 Anti Bakteri DOEN salep , kombinasi : Basitrasin 500 IU /g


Polimiksin 10.000 IU /g
75 900
Dus , 25 tube @ 5 g
13 Asam Asetilsalisilat (asetosal ) tablet 100 mg Dus @ 10 x 10 's 1000 12000
14 Asam Askorbat (vitamin C ) tablet 50 mg Dus 10 strip x 10 tab 10000 120000
15 Asam Mefenamat kapsul /kaplet 500mg Dus , 10 blister @10 kaptab ss 10000 120000

16 Asiklovir tablet /kapsul / kaplet 400 mg 1000 12000


ktk 10 x 10 tablet
17 Atapulgit tablet 600 mg Dus 5 strip @ 10 tablet 10000 120000
18 Bedak salisil serbuk 2% Dus @ 50 gram 25 300
19 Betametason krim 0,1 % (sebagai Velerat ) Tube 5 gr 100 1200
20 Bisakodil Supp 100 1200
21 Deksametason injeksi i.v./i.m. 5 mg / ml Dus ,100 ampul @ 1 ml 200 2400
22 Deksametason 0,5 mg Dus , 10 Strip@10 Tablet 5000 60000
23 Diazepam tab 2 mg tablet 5000 60000
24 Difenhidramin injeksi i.v./i.m. 10 mg / ml (HCl) Dus , @ 30 ampul 120 1440
25 Digoksin tablet 0,25 mg Box 10 x 10 Tab 300 3600
26 Domperidon suspensi / sirup 5 mg / 5 ml btl @ 60 ml 50 600
27 Domperidon tablet 10 mg dus 10 x 10's 1000 12000
28 Eritromisin kapsul /kaplet 500 mg Dus , !0 blister @ 10 kss 500 6000
29 Eritromisin sirup kering 200 mg/ 5 ml Botol @ 60 ml 100 1200
30 Etanol 70 % cairan btl @ 100 tablet 10 120
31 Eugenol cairan Botol 10 ml 10 120
32 Fenobarbital injeksi i.m./i.v. 50 mg/ml Dus @ 30 ampul 30 360
33 Fitomenadion (vit.K1) tablet salut gula 10 mg Dus @ 10 x 10 's 500 6000
34 Fitomenadion (vit.K1) injeksi 5 mg /ml dus @ 30 Ampul 120 1440
35 Furosemid injeksi i.v./i.m. 10 mg/ml Dus , 25 ampul @ 2 ml 25 300
36 Furosemid tablet 40 mg Dus , 10 strip @ 10 tablet 500 6000
Garam Oralit I serbuk , kombinasi : krorida 0,52 g kalium
klorida 0,30 g
37 Dus @ 100 Sachet 500 6000
Trinatrium sitrat dihidrat 0,58 g Glukosa Anhidrat 2,70 g

38 Gentamisin injeksi 40 mg / ml Dus , 5 ampul @ 2 ml 30 360


39 Gentamisin tetes mata 0,3 % Dus , botol plastik 5 ml 50 600
40 Glibenklamind tablet 5 mg Dus , 10 blister @ 10 kaptab 1000 12000
41 Gliklazid tab 80 mg Strip 500 6000
42 Glimepiride tablet 4 mg ktk 5 x 10 tablet 1000 12000
43 Glukosa larutan infus 5 % steril botol @ 500 ml 60 720
44 Griseofulvin tablet 125 mg Dus , 10 blister @ 10 tablet 1000 12000
45 Hidrokortison krim 2,5 % Tube 5 gr 150 1800
46 Ibuprofen sirup 100 mg /5 ml Dus , Botol 60 ml 60 720
47 Ibuprofen tablet 400 mg dus 10 x 10's 500 6000
48 Ibuprofen sirup 100 mg /5 ml Dus , Botol 60 ml 60 720
49 Isosorbid Dinitrat tablet sublingual 5 mg Dus , 10 strip @ 10 tablet 1500 18000
50 Kalsium Laktat (Kalk) tablet / kapsul / kaplet 500 mg Dus , 10 strip @ 10 tablet 6000 72000
51 Kaptopril tablet scored 25 mg Dus , 10 strip @ 10 tablet 5000 60000
52 Ketokonazol krim 2 % tube 5 gr 50 600
53 Ketokonazol tablet 200 mg dus 10 x 5's 1000 12000
54 Ketorolac injeksi 30 mg / ml Dus @ 12 Ampul 100 1200
55 Klindamisin kapsul / kaplet 300 mg Dus , 3 strip @ 10 kapsul 1500 18000
56 Klobazam tab 10 mg Dus , 10 strip @ 10 tablet 300 3600
57 Kloramfenikol salep mata 1 % Tube 5 gr 100 1200
58 Kodein tablet 10 mg ktk 10 x 10 tablet 5000 60000

59 Kombinasi tablet salut : Besi (II) sulfat 7H20 200 mg Asam


folat 0,25 mg
10000 120000
Dus , 100 Sachet @ 30 Tablet
60 Kotrimoksazol DOEN I (dewasa) kombinasi :
Sulfametoksazol 400 mg Trimetoprim 80 mg
4000 48000
Dus , 10 Strip @ 10 Tablet
61 Kotrimoksazol Suspensi komb : Sulfametoksazol 200 mg +
Trimetoprim 40 mg / 5 ml
200 2400
Dus , botol @ 60 ml
62 Lanzoprazol kapsul / kaplet 30 mg Dus , 2 strip @ 10 kapsul 1000 12000

63 Lidokain injeksi 2 % (HCL) + Epinefrin 1 : 80.000 - 2 ml 150 1800


Dus , 30 ampul @ 2 ml
64 Lidokain semprot 10 % Dus , Botol @ 50 ml (500 dosis) 20 240
65 Loperamid tablet 2 mg Dus , 10 strip @ 10 tablet 1000 12000
66 Loratadin tablet 10 mg Dus , 5 strip @ 10 tablet 1000 12000
67 Metformin HCl tablet 500 mg Dus , 10 blister @ 10 tablet 1000 12000

68 Metilergometri
mg
Maleat (Metilergometri) tablet salut 0,125 1000 12000
ktk 10 x 10 tablet salut
69 Metilprednisolon tablet 8 mg Dus , 10 Blister @ 10 tablet 1000 12000
70 Metoklopramid tablet 10 mg Dus @ 10 x 10 's 1000 12000
71 Metronidazol tablet 500 mg 10 strip @ 10 tab 1000 12000
72 Mikonazol krim / salep 2 % (Nitrat) Tube 10 gram 100 1200
73 Naci 0,9 % Botol 500 ml 50 600
74 Natrium Diklofenak tablet 50 mg Dus @ 5 x 10 's 500 6000
75 Nifedipin tablet / kapsul 10 mg Dus , 10 Strip @ 10 tablet salut selaput 1000 12000
76 Nistatin tablet salut 500.000 IU / g Dus @ 10 x 10 's 500 6000
77 Nistatin vaginal tablet 100.000 IU / g Dus @ 10 x 10 's 500 6000
78 Oksitosin injeksi 10 IU / ml Dus , 10 ampul @ 1 ml 250 3000
79 Omeprazol kapsul / kaplet 20 mg dus 10 x 3 's 1000 12000
80 Parasetamol sirup 120 mg / 5 ml botol 60 ml 200 2400
81 Parasetamol tablet 500 mg Dus, 10Strip @ 10Kaplet Salut Selaput 10000 120000
82 Pirantel suspensi 125 mg / 5 ml Botol 60 ml 200 2400
83 Pirantel tablet score (base) 125 mg Dus , 25 Blister @ 4 tablet 1000 12000
84 Povidon Iondida larutan 10 % 30 ml botol @ 30 ml 50 600
85 Povidon Iondida larutan 10 % 300 ml botol @ 300 ml 100 1200
86 Propiltiourasil tablet / kapsul / kaplet 100 mg Botol @ 100 Tablet 600 7200
87 Propranolol tablet 40 mg (HCl) Dus , 10 strip @ 10 tablet 600 7200
88 Ranitidin injeksi 25 mg / ml Dus , 10 ampul @ 2 ml 250 3000
89 Ranitidin tablet 150 mg Dus , 10 Strip @ 10 tablet salut selaput 1500 18000
90 Ringer Laktat larutan infus Botol 500 ml 150 1800
91 Salbutamol tablet 4 mg (sebagai Sulfat ) ktk 10 x 10 tablet 1000 12000

92 Salep 2 - 4 Kombinasi : Asam Salisilat 2% + Belerang


endap 4 %
100 1200
Pot @ 30 gram
93 Sefadroksil sirup kering 125 mg / 5 ml Dus , Botol 60 ml 1000 12000
94 Sefadroksil kapsul / kaplet 500 mg Dus , 10 Strip @ 10 Kapsul 100 1200
95 Sefadroksil sir kering 250 mg / 5 ml Dus , Botol 60 ml 1000 12000
96 Sefiksim kapsul/ kaplet 100 mg Dus , 10 blister @ 10 kapsul 1000 12000
97 Sefotaksim injeksi 1 g Dus , 10 vial @ 1 g 30 360
98 Setirizin sirup 5 mg / 5 ml Botol @ 60 ml 100 1200
99 Setirizin table 10 mg Box , 10 strips @ 10 capsules 1500 18000
100 Slanokobalamin (vitamin B12) injeksi 500 mcg 100 ampul @ 1 ml 200 2400
101 Simvastatin tablet 20 mg Dus , 3 Strip @ 10 kaplet salut selaput 1500 18000
102 Siprofloksasin tablet 500 mg (sebagai HCl) Dus , 10 blister @ 10 tab ss 1500 18000
103 Tetrasiklin tablet / kapsul / kaplet 500 mg DUS , 10 STRIP @ 10 KAPSUL 1000 12000
104 Tramadol injeksi 50 mg / ml Dus , 100 ampul @ 2 ml 100 1200
105 Vitamin B Kompleks tablet Dus , 10 strip x 10 tab 10000 120000
106 Zinc tablet dispersibel 20 mg Dus , 10 strip @ 10 tablet dispersible 8000 96000
107
108
109