C.

OBAT TAMBAHAN Diluar JKN

1 Allopurinol tablet 100 mg Tablet
2 Allopurinol tablet 300 mg Tablet
3 Amlodipin tablet 5 mg Tablet
4 Amlodipin tablet 10 mg Tablet
5 Amitripiline 25 mg Tablet

Analgesik-Psikotropik (mengandung Diazepam

6 2mg+Metamizol 500mg) (Metaneuron)
Tablet

Anti Bakteri DOEN salep kombinasi :

7 Basitrasin 500 IU/g + polimiksin 10.000 IU/g
tube

Antihemoroid DOEN kombinasi : Bismut

8 Subgalat 150 mg + Heksaklorofen 250 mg
Supp

9 Antispasmodik-Analgetik tablet (Spasminal) Tablet

Antimigren : Ergotamin tartrat 1mg + Kofein
10 50mg
Tablet

11 Asam Asetil Salisilat / Asetosal tablet 80mg Tablet

12 Asiklovir tablet 200 mg Tablet
13 Betametason krim 0,1 % tube
14 Bisakodil Suppositoria (Dulcolax) Supp
15 Diazepam tablet 2 mg Tablet
16 Fitomenadion (Vit. K1) tablet salut gula 10 mg Tablet
17 Furosemid injeksi Ampul
18 Flukonazol tablet 150mg Tablet
19 Garam Oralit Serbuk Kombinasi Tablet
Botol 500
20 Glukosa Larutan Infus 10%
ml
Botol 500
21 Glukosa Larutan Infus 5%
ml
22 Hidroklortiazid tab 25 mg Tablet
23 Hystolan 20 mg Tablet
24 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet
25 Kalsium Laktat (Kalk) tablet 500 mg Tablet
26 Kalsium Laktat (Kalk) tablet 500 mg Tablet
27 Kaporit Pail
28 Kloramfenikol sirup 125 mg/5 ml Botol 60 ml
29 Klorfeniraniramina Maleat (CTM) tablet 4 mg Tablet
Kotrimosakzol DOEN I (dewasa) Kombinasi :
30 Sulfametoksazol 400 mg, Trimetoprim 80 mg
Tablet

31 Lansoprazole capsul 30mg Tablet

Lidokain injeksi 2% (HCL) + Epinefrin 1 :
32 80.000-2 ml
Ampul

33 Lisol Botol
34 Magnesium Sulfat inj (IV) 20 %-25 ml Vial
35 Metformin HCl tablet 500 mg Tablet
36 Metilergometrin Maleat tablet salut 0,125 mg Tablet
37 Metilprednisolon tablet 4 mg Tablet
38 Metronidazol tablet 250 mg Tablet
39 Metronidazol Tablet 500 mg Tablet
40 Mikonazole krim / salep 2% (nitrat) tube
41 Mikonazole serbuk (Mycorine) Botol
 Multivitamin Sirup (Per 5 mL sir Vit A 2,000 iu,
vit B1 1 mg, vit B2 0.5 mg, vit B6 1 mg, vit B12
1 mcg, vit C 10 mg, vit D 400 iu, Ca
42 pantothenate 5 mg, Ca gluconate 50 mg, DHA
Botol
8 mg, lysine HCl 100 mg, colostrum bovine
250 mg.) (Truvit)

43 N-asetil sistein 100 mg nebules inj (Fluimucil) Ampul

44 Natrium Bikarbonat tablet 500 mg Tablet
45 Natrium Diklofenak 50 mg Tablet
46 Nistatin Vaginal tablet salut 100.000 IU/g Tablet

Obat Flu Kombinasi Syrup (Tiap 5ml

mengandung: Paracetamol 120mg, Glyseril
47 Guaiakolat 25mg, Klorfeniramin maleat 1mg,
Botol
Phenylephrine HCL 5mg) (Solaflu)

Obat Untuk Saluran Cerna (Tablet kombinasi:

48 Pancreatin 170mg, simethicone 80mg) Tablet
(Flazymec)
49 Omeprazole kapsul 10 mg Kapsul
50 Omeprazole kapsul 10 mg Kapsul
51 Parasetamol tablet 500 mg Tablet
52 Piridoksin (Vitamin B6) tablet 10 mg (HCL) Tablet
53 Povidon Iodida larutan 10 % Botol 30 ml
54 Prednison tablet 5 mg Tablet
55 Salbutamol cairan IH 0,5% (Ventolin Nebule) Ampul
56 Salbutamol sirup Botol
Salep 2-4, kombinasi: Asam Salisilat 2% +
57 Belerang endap 4%
Pot
Kotak 50
58 Salisil bedak 2%
gram
59 Sefadroksil kapsul 500 mg Kapsul
60 Setirizin tablet Tablet
61 Simvastatin 10mg Tablet
62 Siprofloksasin 500mg Tablet
63 Tramadol injeksi 50 mg/ml Ampul
Alat Kesehatan
Set
1 Alat suntik sekali pakai 2,5 ml
/kantong
2 Alkohol Swab 100 pcs/box
3 Aqua Pro Injeksi Steril, bebas pirogen vial @20ml
4 Aqua Pro Injeksi Steril, bebas pirogen vial @20ml
5 Bisturi No 11 (Aesculap) Buah
6 HCG Strip pcs
Set
7 Infusion set anak
/kantong
Set
8 Infusion set dewasa
/kantong
9 IV Catheter No. 18 G pcs
10 IV Catheter No. 20 (Adsyte 20) pcs
50 buah /
11 IV Catheter No. 22 G wings
kotak
12 IV Catheter No. 24 G Pcs
13 IV Catheter No. 24 G wings 50 buah / kotak
14 Kasa Kompres 40/40 steril Bungkus
15 Object Glass Buah
16 Plester 7,5 x 4,5cm (Hansaplast) Rol
17 Pot Dahak (Pot Sputum) Buah
18 Tapping (Self Tapping Vertebral Screw) roll
IMUNISASI
1 Vaksin Anti Rabies (Verorab) Kuur
2 Vaksin BCG Vial
3 Vaksin DT Vial
4 Vaksin Polio IPV 5 ds (Poliomyelitis) Vial
5 Vaksin Jerap DT cairan inj @ 5 ml (10 dosis) Vial
Vaksin Jerap Difteri Tetanus cairan inj (50
6 dosis)
Vial

7 Vaksin HB Uniject (Hepatitis B Rekombinan) Pair

8 Ads 0,5 ml pcs
9 Ads 0,05 ml Oneject Buah
10 Ads 0,05 ml Oneject/2018 Buah
11 Ads 5 ml Buah
12 Safety Box Pcs
13 Safety Box Pcs
14 Ads 0,5 oneject Buah
TB PARU (OAT FDC)
1 OAT kategori 1 Paket
2 Kaca Slide Kotak
GIZI
1 Iodine Test
Kotak @100
2 Tablet Fe (Ferro Fumarat) 200mg
tab
KEJIWAAN
1 Amitriptillin Tablet Salut 25mg Tablet
2 Amitriptillin Tablet Salut 25mg Tablet
3 Clozapine Tablet 25mg Tablet
4 Haloperidol Inj. 5 mg/ml Ampul
5 Haloperidol Tablet 5 mg Tablet
6 Haloperidol Tablet 5 mg Tablet
7 Haloperidol Tablet 5 mg Tablet
8 Klorpromazine Hcl Tablet Salut 100mg Tablet
9 Klorpromazine Hcl Tablet Salut 100mg Tablet
10 Risperidone Tablet 2mg Tablet
11 Risperidone Tablet 2mg Tablet
12 Triheksifenidil Tablet Tablet
13 Triheksifenidil Tablet Tablet
KIA
1 Ca Glukonas Injeksi 10 ml Ampul
2 Gentamicin injeksi 40 mg Ampul
3 Magnesium Sulfate Injeksi 20 % Botol
4 Metil ergometrin maleat inj 0,3 mg Ampul
5 Onemed Glucose + Protein Test Ampul
6 U-PAD (U-PAD 60x90) Pcs
DBD
1 Bactivec Botol
 2 RDT DBD Combo ( IgG dan NS1 ) Test
HIV
1 Jarum Lanset Dus
2 Kasa Alkohol/HIV Box
3 Label Pack
4 Lampu Spirtus Buah
5 Mikro Pipet 5-50 ul Buah
6 Pen Lanset Buah
7 Rapid Test Syphilis Monotest Box
8 Tabung Vacutrimer/HIV Box

9 Tip Kuning/2018 Box@100pcs

10 Torniquett Buah
D. JKN/BPJS
1 Donperidone Syr 60 ml Botol
2 Gentamicin injeksi Ampul
3 Ketorolac inj 30 mg Ampul
4 Amoksisilin 125 mg Botol
5 Erythromicyne Kaplet 500 mg Tablet
6 Furosemid 40 mg Tablet
7 Lidokain injeksi 2% Ampul
8 Ondansentron 4 mg Injeksi 2 ml Ampul
9 Accu check Performa Strip
10 Blood Lancet 26G Onemed Dus
11 One Scrub Botol
12 Oxyflow (Oxygen Nasal) Buah
13 Natrium Clorida Botol
14 Gentamisin Salep Kulit Tube
15 L-BIO Sachet
16 Thiampenicol 500 mg Tablet
17 Meloxicam 7,5 mg Tablet
18 Piroxicam 10 mg Tablet
19 Ambroxol Tablet
Hyosin n buthylbromide 10 mg, Paracetamol
20 (SCOPMA)
Tablet

21 Stesolid/Diazepam Tube
22 Metronidazole Syp 200mg Botol
23 Neo K inj Ampul
24 Lodecon Tablet
25 Paracetamol 500 mg Tablet
26 Antasida Tablet
27 Solaflus Botol
28 Salbutamol Tablet
29 Asiklovir krim 5% Tube
30 Ambroxol Tablet
31 Biomega Tablet
32 Cendo Lyters Botol
33 Dextral Forte Tablet
34 Gentalex Krim Tube
35 Histigo Tablet
36 Human Cens Cholesterol Strip
37 Lodecon Forte Tablet
38 Meloxicam 7,5 mg Tablet
39 Metilprednisolon tablet 4 mg Tablet
40 Neucompli Tablet
41 Reco Tetes Telinga Botol
42 Rexavin 125 mg Tablet
43 Sarung Tangan Obgyn Steril pcs
44 One Scrub Botol
45 Maxter Exam M Box
46 Maxter Exam L Box
47 Gemfibrozil 600 mg Kaplet