No Nama Obat Generik Nama Dagang Nama Penyedia KemasanHarga Satuan Terkecil (Rp)

1 ACT (Artesunate tablet 50 mg + Amodiaquine anhydrida tablet 200 mg)n/a PT. Kimia Farma 1 blister@24 tablet 1,375.002 Albendazol suspensi 200 mg/5 ml n/a PT. Indofarma Dus, 10 dus @ 1 botol @ 10 ml 3,849.003 Albendazol tablet/kapsul/kaplet 400 mg n/a PT. Holi Pharma Dus, 5 strip @ 6 tablet 3444 Alopurinol tablet/kapsul/kaplet 100 mg n/a PT. Pertiwi Agung Box, 10 strips @ 10 tablets 865 Alprazolam tablet/kapsul/kaplet 0,25 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 3806 Alprazolam tablet/kapsul/kaplet 0,5 mg n/a PT. Kimia Farma Ktk 10x10 tablet 2147 Alprazolam tablet/kapsul/kaplet 1 mg n/a PT. Kimia Farma Ktk 10x10 tablet 2338 Amikasin injeksi 250 mg/ml Glybotic 250 mg /ml PT. Sanbe Farma Vial 2 ml 50,500.009 Aminofilin injeksi 24 mg/ml n/a PT. Lucas Djaja dus 30 ampul @10 ml 3,822.00

10 Aminofilin tablet scored 200 mg n/a PT. Erela Botol @100 Tablet 8011 Amiodaron injeksi 150 mg/3 ml Cordarone PT. Aventis Pharma Dus, 6 ampul @ 3 ml 12,480.0012 Amiodaron tablet/kaplet 200 mg Kendaron Tablet PT. Darya Varia strip 1,200.0013 Amitriptilin tablet salut 25 mg (HCl) n/a PT. Indofarma Dus, 10 strip @ 10 tss 11214 Amlodipin tablet 10 mg n/a PT. Pertiwi Agung Box, 3 strips @ 10 tablets 33015 Amlodipin tablet 5 mg n/a PT. Pertiwi Agung Box, 3 strips @ 10 tablets 18716 Amoksisilin kapsul/kaplet 250 mg n/a PT. Novapharin strip 21117 Amoksisilin kapsul/kaplet/tablet scored 500 mg n/a PT. Mersifarma KOTAK @ 10 x 10 TAB 26118 Amoksisilin sirup kering forte 250 mg/5 ml n/a PT. Holi Pharma Dus, Botol 60 ml 4,070.0019 Amoksisilin sirup kering 125 mg/ 5 ml n/a PT. Novapharin btl @ 60 ml 2,445.00

20Analog insulin rapid actinginj 100 UI/ml, vial/cartridge disposible/penfill cartridge (Insulin

Apidra Solostar 100IU/ml 5pens x3ml PT. Aventis Pharma dus, 5 solostar pen @ 3ml 79,165.00

21Antasida DOEN I tablet kunyah, kombinasi : Aluminium Hidroksida 200 mg Magnesium

n/a PT. Erela Dus, 10 Strip @ 10 Tablet 72

22Antasida DOEN II suspensi, kombinasi : Aluminium Hidroksida 200 mg/5 ml Magnesium Hidroksida 200

n/a PT. Erela Botol @ 60 ml 2,160.00

23Anti Bakteri DOEN salep kombinasi: Basitrasin 500 IU/g Polimiksin 10.000 IU/g

n/a PT. Indofarma Dus, 25 tube @ 5 g 2,516.00

24Antimalaria DOEN kombinasi : Pirimetamin 25 mg Sulfadoksin 500 mg

n/a PT. Kimia Farma ktk 10 x 10 tablet 520

25 Antimigren: Ergotamin Tartrat 1 mg + Kofein 50 mg n/a PT. Kimia Farma Btl 100 tablet 135

26Antiparkinson DOEN tablet kombinasi : Benserazid 25 mg Levodopa 100 mg

Levopar Tablet PT. Meprofarm Dus, 5 strip @ 10 tablet 1,500.00

27 Artemether injeksi 80 mg/ml Artem PT. Kimia Farma Dus 6 amp @ 1ml 22,000.0028 Asam Askorbat (Vitamin C) tablet 50 mg n/a PT. Kimia Farma Dus 10 strip x 10 tab 9529 Asam Folat tablet/kapsul/kaplet 1 mg n/a PT. Marin Liza Farmasi Botol @ 100 tablet 4830 Asam Mefenamat kapsul/kaplet 500 mg n/a PT. Bernofarm Dus, 10 blister @ 10 kaptab ss 11231 Asam pipemidat kapsul 400 mg Urotractin 400 mg PT. Sanbe Farma Strip 1,815.0032 Asam traneksamat injeksi 100 mg/ml n/a PT. Hexpharm Jaya Laboratories Dus, 10 ampul @ 5 ml 3,334.0033 Asiklovir salep mata 3% Temiral Eye Oint PT. Sanbe Farma Tube 3,5 gram 24,750.0034 Asiklovir tablet/kapsul/kaplet 200 mg n/a PT. Indofarma Dus, 10 blister @ 10 tablet 23735 Asiklovir tablet/kapsul/kaplet 400 mg n/a PT. Sampharindo Perdana Dus, 5 strip @ 10 tablet 33636 Atapulgit tablet 600 mg Pularex PT. Zenith Pharmaceuticals Dus 5 strip @ 10 tablet 19037 Atrakurium injeksi 25 mg/2,5 ml Tracrium PT. Glaxo Wellcome Indonesia Dus, 5 ampul @ 2.5 ml 20,000.0038 Atropin Sulfat tablet 0,5 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 7439 Azitromisin sir kering 200 mg/ 5 mL n/a PT. Soho Industri Pharmasi botol @ 60 ml 34,400.0040 Azitromisin tablet 500 mg n/a PT. Kimia Farma ktk 2x10 tablet 4,500.0041 Azitromisin tablet 250 mg n/a PT. Soho Industri Pharmasi Strip 3,333.3342 Bedak salisil serbuk 2% n/a PT. Rama Emerald Multi Sukses Dus @ 50 gram 1,250.0043 Benzatin Benzil Penisilin 1,2 juta IU/ vial n/a PT. Phapros, Tbk Dus @ 10 Vial 9,800.0044 Benzatin Benzil Penisilin 2,4 juta IU/vial n/a PT. Phapros, Tbk Dus @ 10 Vial 13,400.0045 Beractant injeksi / suspensi 25 mg/mL Survanta PT. Abbott Indonesia Vial 3,200,000.0046 Beraprost sodium tablet 20 mcg Dorner PT. Combiphar Box @ 3 blister @ 10 Tablet 3,600.0047 Beraprost sodium tablet 20 mcg Dorner 20 µg PT. Combiphar Box/ 3 blister @ 10 Tablet 3,600.0048 Betametason krim 0,1% (sebagai Valerat) n/a PT. Kimia Farma Tube 5 gr 1,520.0049 Bisakodil suppositoria 10 mg Stolax supp PT. Sanbe Farma Supp 6,045.0050 Bromokriptin tablet 2,5 mg Cripsa tab PT. Caprifarmindo Box 3 x 10'S 247,089.0051 Deksametason injeksi i.v./i.m. 5 mg/ml n/a PT. Indofarma Dus, 100 ampul @ 1 ml 1,580.0052 Deksametason tablet 0,5 mg n/a PT. Promedrahardjo Farmasi Industri STRIP 6253 Desoksimetason krim 0,25% n/a PT. Dexa Medica Kotak, tube @ 15 gram 9,983.0054 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) n/a PT. Phapros, Tbk Dus @ 30 Ampul 1,050.0055 Digoksin tablet 0,25 mg n/a PT. Yarindo Farmatama Box 10 X 10 Tab 9756 Diltiazem HCl tablet 30 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 13457 Diltiazem injeksi 25 mg/5 mL Farmabes Injeksi 25 mg PT. Pratapa Nirmala Vial 5 mL 46,667.0058 Dimenhidrinat tablet 50 mg n/a PT. Kimia Farma Btl 100 tablet 10459 Doksazosin mesilat tablet 1 mg Cardura 1mg PT. Pfizer Indonesia Dus, 5 blister @10's tab 3,480.0060 Doksazosin mesilat tablet 2 mg Cardura 2mg PT. Pfizer Indonesia Dus, 5 blister @10's tab 5,480.0061 Doksorubisin serbuk injeksi i.v. 10 mg/vial Doxorubicin Actavis 10 mg PT. Actavis Indonesia Dus, 1 vial @ 10 mg 55,500.0062 Doksorubisin serbuk injeksi i.v. 50 mg/vial Doxorubicin Actavis 50 mg PT. Actavis Indonesia Dus, 1 vial @ 50 mg 258,000.0063 Domperidon suspensi/sirup 5 mg/5 ml n/a PT. Novapharin btl @ 60 ml 3,333.0064 Domperidon tablet 10 mg n/a PT. Novapharin strip 16765 Domperidon tetes 5 mg/mL n/a PT. Bernofarm Dus, botol @ 10 ml 15,600.0066 Enoksaparin sodium inj 20 mg/0,2 mL Lovenox 2000 ANTI-XA PT. Aventis Pharma dus, 2 prefilled syringe @ 0,2 ml 40,740.0067 Enoksaparin sodium inj 40 mg/0,4 mL Lovenox 4000 ANTI-XA PT. Aventis Pharma dus, 2 prefilled syringe @ 0,4 ml 71,875.0068 Enoksaparin sodium inj 60 mg/0,6 mL Lovenox 6000 ANTI-XA PT. Aventis Pharma dus, 2 prefilled syringe @ 0,6 ml 100,000.0069 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml n/a PT. Phapros, Tbk Dus @ 30 Ampul 8,100.0070 Epirubisin serb injeksi 50 mg/25ml Epirubisin Kalbe PT Kalbe Farma Vial @ 25 ml 500,000.0071 Ergokalsiferol (vitamin D3/D2) kapsul 50.000 UI D-Vit FT PT. Gracia Pharmindo Dus 3 strip @ 10 Flash tablet 65072 Eritromisin kapsul/kaplet 250 mg n/a PT. Kimia Farma ktk 10 x 10 kapsul 49773 Eritromisin kapsul/kaplet 500 mg n/a PT. Indofarma Dus, 10 blister @ 10 kss 93074 Eritromisin sirup kering 200 mg/ 5 ml n/a PT. Phyto Kemo Agung Farma Botol @60 ml 7,700.0075 Etambutol tablet 250 mg (HCl) n/a PT. Kimia Farma ktk 20 x 10 tablet 31476 Etambutol tablet salut 500 mg (HCl) n/a PT. Indofarma Dus, 10 strip @ 10 tss 45177 Etanol 70% cairan n/a PT. Novapharin btl @ 100 ml 2,500.0078 Etoposid injeksi 20 mg/ml Posyd PT. Combiphar Vial 100mg/5ml 100,000.00

E-KATALOG OBAT 2014

79 Eugenol cairan n/a PT. Kimia Farma Botol 10 ml 16,667.0080 Fenitoin injeksi 50 mg/ml n/a PT. Mersifarma KOTAK @ 10 ampul 20,250.0081 Fenitoin kapsul/kaplet 100 mg n/a PT. Ikapharmindo Botol @ 100 13382 Fenobarbital injeksi i.m./i.v. 50 mg/ml n/a PT. Phapros, Tbk Dus @ 30 Ampul 1,800.0083 Fenofibrat kaps 100 mg n/a PT. Hexpharm Jaya Laboratories Dus, 3 strip @ 10 kapsul 1,075.0084 Fenofibrat kaps 300 mg n/a PT. Hexpharm Jaya Laboratories Dus, 3 strip @ 10 kapsul 1,375.0085 Fenoksimetil penisilin (penisilin V) tablet 250 mg n/a PT. Phapros, Tbk Dus @ 10 X 10 's 29086 Fenoksimetil penisilin (penisilin V)tablet 500 mg n/a PT. Phapros, Tbk Dus @ 10 X 10 's 51087 Fentanil injeksi i.m/i.v 0,05 mg/ml, ampul 10 ml n/a PT. Kimia Farma Dus 5 ampul@ 10ml 128,000.0088 Fentanil injeksi i.m/i.v 0,05 mg/ml, ampul 2 ml n/a PT. Kimia Farma Dus 5 ampul@ 2ml 33,914.0089 Fentanil patch 25 mcg/jam Durogesic 25 MU Matrix PT. Kimia Farma Dus@ 5 patch 153,000.0090 Fentanil patch 50 mcg/jam Durogesic 50 MU Matrix PT. Kimia Farma Dus@ 5 patch 285,000.0091 Filgrastim inj 300 mcg/mL Leucogen PT Kalbe Farma pfs @ 0,5 ml 375,000.0092 Filgrastim inj 300 mcg/mL Zarzio PT. Sandoz Indonesia pfs @ 0,5 ml 380,000.0093 Fitomenadion (Vit.K1) tablet salut gula 10 mg n/a PT. Phapros, Tbk Dus @ 10 X 10 's 63094 Flufenazin injeksi i.m. 25 mg/ml Sikzonoate Injeksi PT. Mersifarma Dus, 5 ampul @ 1ml 55,000.0095 Flukonazol injeksi 2 mg/ml n/a PT. Natura Laboratoria Farma Dus, 1 Botol @ 100 mL 47,550.0096 Flukonazol tablet/kapsul 150 mg n/a PT. Kimia Farma ktk 1 x 10 kapsul 22,000.0097 Fluoksetin tablet 10 mg Foransi 10 PT. Gracia Pharmindo strip 41998 Fluoksetin tablet 20 mg NOPRES PT. Dexa Medica DUS, 30 TABLET 43299 Fluorourasil inj 250 mg/mL Curacil PT Kalbe Farma vial @ 1 ml 24,500.00

100 Fluorourasil inj 500 mg/ 5 mL Curacil PT Kalbe Farma vial @ 10 ml 33,000.00

No Nama Obat Generik Nama Dagang Nama Penyedia KemasanHarga Satuan Terkecil (Rp)

101 Flusinolon asetonid krim 0,025% SYNARCUS PT. Ifars Dus, Tube 5 g 2,400.00102 Flutikason furoat intranasal spray Avamys PT. Glaxo Wellcome Indonesia Dus, Botol 120 Dosis Spay 93,333.33103 Flutikason propionat nebules 0,5 mg Flixotide Nbules PT. Glaxo Wellcome Indonesia Dus, 2 flow wrap@ 5 nebules @ 1 dosis (2ml)12,916.67104 Fondaparinuks inj 2,5 mg/0,5 mL Arixtra PT. Glaxo Wellcome Indonesia Dus, 2 pfs 0.5 ml 241,666.67105 Furosemid injeksi i.v./i.m. 10 mg/ml n/a PT. Indofarma Dus, 25 ampul @ 2 ml 1,829.00106 Furosemid tablet 40 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 85107 Gemfibrozil kapsul/kaplet 300 mg n/a PT. Indofarma Dus, 10 blister @ 12 kapsul 289108 Gemfibrozil tablet 600 mg n/a PT. Indofarma Dus, 10 blister @ 10 kaptab 679109 Gemsitabin inj 1000 mg/vial Gemzar 1000 mg PT. Bayer Indonesia vial 1,098,900.00110 Gentamisin injeksi 40 mg/ ml n/a PT. Indofarma Dus, 5 ampul @ 2 ml 3,399.00111 Gentamisin salep mata 0,3% Genoint Salep Mata PT. Erela Tube @ 3,5 gr 2,600.00112 Gentamisin tetes mata 0,3% n/a PT. Indofarma Dus, botol plastik 5 ml 3,194.00113 Glibenklamid tablet 5 mg n/a PT. Indofarma Dus, 10 blister @ 10 kaptab 56114 Gliklazid tab 80 mg GLUCODEX PT. Dexa Medica DUS, 100 TABLET 236115 Glikuidon tab 30 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 950116 Glimepiride tablet 1 mg n/a PT. Kimia Farma ktk 5x10 tablet 265117 Glimepiride tablet 2 mg n/a PT. Kimia Farma ktk 5x10 tablet 436118 Glimepiride tablet 3 mg n/a PT. Kimia Farma ktk 5x10 tablet 404119 Glimepiride tablet 4 mg n/a PT. Kimia Farma ktk 5x10 tablet 430120 Gliseril trinitrat tab sublingual 0,5 mg Nitral PT. Actavis Indonesia Btl @ 30 tablet 1,500.00121 Gliserin lar 50% Gliserin lar 50% PT. Lucas Djaja Glycerin 100 ml 5,333.00122 Glukosa larutan infus 10 % steril n/a PT. Widatra Bhakti botol @ 500 ml 5,700.00123 Glukosa larutan infus 5 % steril n/a PT. Widatra Bhakti botol @ 500 ml 5,200.00124 Griseofulvin tablet 125 mg n/a PT. Phapros, Tbk Dus @ 10 X 10 's 209125 Haloperidol inj 50 mg/mL Haldol Decanoas PT. Soho Industri Pharmasi Dus 5 Ampul@1mL 83,333.33126 Haloperidol tablet 0,5 mg n/a PT. Indofarma Dus, 10 blister @ 10 tablet 59127 Haloperidol tablet 5 mg n/a PT. Indofarma Dus, 10 blister @ 10 tablet 96128 Haloperidol tablet 1,5 mg n/a PT. Indofarma Dus, 10 blister @ 10 tablet 69129 Haloperidol tablet 2 mg Lodomer 2 PT. Mersifarma KOTAK @ 10 x 10 TAB 126130 Hiosin butilbromid injeksi 20 mg/ml n/a PT. Otto Pharmaceuticals box 5ampul @1 ml 4,500.00131 Ibuprofen sirup 100 mg/5 ml n/a PT. Indofarma Dus, botol 60 ml 3,499.00132 Ibuprofen suspensi 200 mg/5 ml n/a PT. Indofarma Dus, botol 60 ml 4,499.00133 Ibuprofen tablet 400 mg n/a PT. Novapharin strip 150134 Irbesartan tab 150 mg n/a PT. Indofarma Dus, 5 blister @ 10 kss 1,425.00135 Irbesartan tab 300 mg n/a PT. Indofarma Dus, 5 blister @ 10 kss 2,470.00136 Isosorbid Dinitrat tablet sublingual 5 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 88137 Kandesartan tab 16 mg n/a PT. Dexa Medica Dus, 3 Blister @ 10 tablet 4,900.00138 Kandesartan tab 8 mg n/a PT. Dexa Medica Dus, 3 Blister @ 10 tablet 3,100.00139 Kaptopril tablet 50 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 140140 Kaptopril tablet scored12,5 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet 62141 Karbamazepin tablet 200 mg n/a PT. Indofarma Dus, 10 blister @ 10 tablet 245142 Karbogliserin tetes telinga 10% Karbogliserin tetes telinga 10% PT. Lucas Djaja Fenol 100 mg / 1 ml 2,042.00143 Ketamin injeksi i.v. 100 mg/ml KTM PT. Guardian Pharmatama Vial @ 10 ml 110,000.00144 Ketokonazol krim 2% n/a PT. Kimia Farma tube 10 gr 2,569.00145 Ketokonazol krim 2% n/a PT. Novell Box isi 1 Tube @ 15 g 4,700.00146 Ketokonazol tablet 200 mg n/a PT. Dexa Medica Dus, 5 Strip @ 10 tablet 300147 Ketorolac injeksi 30 mg/ml n/a PT. Phapros, Tbk Dus @ 12 Ampul 2,300.00148 Klaritromisin tab 500 mg ORIXAL PT. Ifars Dus, 3 Strip @ 10 Kaplet salut selaput 3,200.00149 Klindamisin kapsul/kaplet 150 mg n/a PT. Indofarma Dus, 5 blister @ 10 kapsul 361150 Klindamisin kapsul/kaplet 300 mg n/a PT. Indofarma Dus, 5 blister @ 10 kapsul 553151 Klobazam tab 10 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 900152 Klonidin tablet 0,15 mg n/a PT. Kimia Farma Ktk 10X10 TAB 184153 Klopidogrel tab 75 mg n/a PT. Hexpharm Jaya Laboratories Dus, 3 strip @ 10 tab 3,400.00154 Kloramfenikol salep mata 1 % n/a PT. Kimia Farma Tube 5 gr 1,600.00155 Klorpromazin injeksi i.m. 25 mg/ml (HCl) n/a PT. Phapros, Tbk Dus @ 30 Ampul 1,100.00156 Klorpromazin injeksi i.m 5 mg/ml - 2 ml (HCl) n/a PT. Phapros, Tbk Dus @ 30 Ampul 1,050.00157 Kodein tablet 10 mg n/a PT. Kimia Farma ktk 10x10 tablet 500158 Kodein tablet 15 mg n/a PT. Kimia Farma ktk 10x10 tablet 850159 Kodein tablet 20 mg n/a PT. Kimia Farma ktk 10x10 tablet 1,100.00

160 Kombinasi suspensi : Parafin + gliserin + fenolftalein Laxadine Emulsi 60 ml PT. Galenium Pharmasia Laboratories Botol @ 60 ml 12,450.00

161Kombinasi tablet salut : Besi (II) sulfat 7H2O 200 mg Asam folat 0,25 mg

n/a PT. Erela Dus, 100 Sachet @ 30 Tablet 42

162Kombinasi: Salmeterol 25 mcg; Flutikason propionat 50 mcg

Seretide Inhaler 50 mcg PT. Glaxo Wellcome Indonesia Dus, Botol 120 Dosis 90,666.67

163Kombinasi: Salmeterol 50 mcg; Flutikason propionat 100 mcg

Seretide Diskus 100 mcg PT. Glaxo Wellcome Indonesia Dus, foil strip @ 60 dosis 100,833.33

164Kombinasi: Salmeterol 50 mcg; Flutikason propionat 250 mcg

Seretide Diskus 250 mcg PT. Glaxo Wellcome Indonesia Dus, foil strip @ 60 dosis 113,333.33

165Kotrimoksazol DOEN I (dewasa) kombinasi : Sulfametoksazol 400 mg Trimetoprim 80 mg

n/a PT. Promedrahardjo Farmasi Industri STRIP 138

166Kotrimoksazol Suspensi komb: Sulfametoksazol 200 mg + Trimetoprim 40 mg / 5 ml

n/a PT. Sampharindo Perdana Botol, 60 ml 2,167.00

167 Kuinin (Kina) tablet 200 mg n/a PT. Kimia Farma ktk 60 tablet 670168 Kuinin injeksi i.v. 25% (sebagai 2 HCl) n/a PT. Kimia Farma ktk 100 amp @ 2 ml 6,200.00169 Kuinin tablet 222 mg (H2SO4.7H2O) n/a PT. Kimia Farma ktk 10 x 10 tablet 540170 Lamivudine tablet 150 mg n/a PT. Kimia Farma Botol 60 tablet 1,400.00171 Lanzoprazol kapsul/kaplet 30 mg n/a PT. Indofarma Dus, 2 strip @ 10 kapsul 473

172 Larutan mengandung Asam Amino (Asam amino 8%) Aminosteril N-Hepa PT. Fresenius Kabi Combiphar Botol Gelas 500 ml 78,720.00

173Larutan mengandung Karbohidrat + Elektrolit (Glukosa: 25,0 g; NaCl: 4,5 g)

WIDA 2A PT. Widatra Bhakti Botol 500 ml 6,917.00

174Larutan mengandung Karbohidrat + Elektrolit (Glukosa: 55.0 g; NaCl: 2.25 g)

WIDA D5-1/4NS PT. Widatra Bhakti Botol 500 ml 7,700.00

175Larutan mengandung Karbohidrat + Elektrolit (Glukosa: 55.0 g; NaCl: 4.5 g)

WIDA D5-1/2NS PT. Widatra Bhakti Botol 500 ml 7,700.00

176 Larutan mengandung Lipid (Emulsi lemak 20%) Intralipid PT. Fresenius Kabi Combiphar Botol Gelas 100 ml 60,500.00177 Levofloksasin inf 5 mg/mL n/a PT. Infion Pharmaceutical Box, 1 Botol @ 100 ml 40,000.00178 Levofloksasin tablet 500 mg n/a PT. Promedrahardjo STRIP 528179 Lidokain injeksi 2% (HCL) n/a PT. Bernofarm Dus, 100 ampul @ 2 ml 839180 Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 n/a PT. Indofarma Dus, 30 ampul @ 2 ml 1,363.00181 Lisinopril tablet 10 mg n/a PT. Novell Box ,3 Strip @ 10 tablet 600182 Lisinopril tablet 5 mg n/a PT. Novell Box ,3 Strip @ 10 tablet 350183 Loperamid tablet 2 mg n/a PT. Ifars Dus, 10 Strip @ 10 Tablet 89184 Loratadin tablet 10 mg n/a PT. Promedrahardjo STRIP 154185 Lorazepam tablet 2 mg Merlopam 2 PT. Mersifarma KOTAK @ 10 x 10 TAB 1,341.00186 Maprotilin HCl tab 25 mg Ludios PT. Soho Industri Pharmasi Strip 1,200.00187 Maprotilin HCl tab 50 mg Sandepril 50 PT. Mersifarma KOTAK @ 5 x 10 TAB 3,276.00188 Meropenem inj 1 g n/a PT. Bernofarm Dus, 1 vial @ 1 g 54,000.00189 Metadon sir 50mg/5ml n/a PT. Kimia Farma Botol 1000 ml 254,100.00190 Metilergometrin Maleat tab salut 0,125 mg n/a PT. Kimia Farma ktk 10 x 10 tablet salut 154191 Metilprednisolon tablet 16 mg n/a PT. Mahakam Beta Farma Strip 635192 Metilprednisolon tablet 4 mg n/a PT. Natura Laboratoria Farma Dus, 10 Blister @ 10 Tablet 205193 Metilprednisolon tablet 8 mg n/a PT. Dexa Medica Dus, 10 Blister @ 10 tablet 300194 Metoklopramide tablet 5 mg n/a PT. Kimia Farma ktk 10 x 10 tablet 108195 Metronidazol infus 500 mg/100 ml n/a PT. Natura Laboratoria Farma Dus, 1 Botol @ 100 ml 9,950.00196 Metronidazol supositoria 500 mg Flagyl PT. Aventis Pharma Dus, 2 blister @ 5 suppositoria 3,220.00197 Metronidazol tablet 250 mg n/a PT. Phyto Kemo Agung Farma 10 strip @ 10 tab 110198 Metronidazol tablet 500 mg n/a PT. Phyto Kemo Agung Farma 10 strip @ 10 tab 160199 Midazolam injeksi i.v. 1 mg/ml Fortanest PT Kalbe Farma Box isi 5 ampul 6,000.00200 Midazolam injeksi i.v. 5 mg/ml Dormicum PT. Boehringer Ingelheim Boks 5 amp 12,060.00

No Nama Obat Generik Nama Dagang Nama Penyedia KemasanHarga Satuan Terkecil (Rp)

201 Mikonazol krim/salep 2 % (Nitrat) n/a PT. Kimia Farma Tube 10 gram 3,000.00202 Mometason furoat krim 0,1% n/a PT. Guardian Pharmatama tube 10 gram 17,820.00203 Morfin HCL inj 10 mg/ml n/a PT. Kimia Farma Dus 10 amp @ 1 ml 8,400.00204 Morfin injeksi i.m./s.k./i.v. 10 mg/ml n/a PT. Kimia Farma Ktk 10 ampul @ 1ML 10,499.00205 Morfin tablet 10 mg n/a PT. Kimia Farma Botol 30 tablet 1,300.00206 Nacl 0,9% n/a PT. Widatra Bhakti Botol 500 ml 4,700.00207 Nadroparin inj 9500 Axa/mL syringe 0,3 mL Fraxiparine 0.3 ml PT. Glaxo Wellcome Indonesia Dus, 5 blister @ 2 pfs 0.3 ml 54,144.17208 Nadroparin inj 9500 Axa/mL, syringe 0,4 mL Fraxiparine 0.4 ml PT. Glaxo Wellcome Indonesia Dus, 5 blister @ 2 pfs 0.4 ml 66,640.00209 Nadroparin inj 9500 Axa/mL, syringe 0,6 mL Fraxiparine 0.6 ml PT. Glaxo Wellcome Indonesia Dus, 5 blister @ 2 pfs 0.6 ml 94,961.67210 Nalokson injeksi 0,4 mg/ml Nokoba PT. Pratapa Nirmala Dus, 5 Ampul @ 2ml 61,600.00211 Natrium fusidat salep 20 mg/g Fucilex Ointment PT. Molex Ayus Tube 5 gr 6,490.00212 Nevirapin tablet 200 mg n/a PT. Kimia Farma btl 60 tablet 2,800.00213 Nifedipin tab 20 mg, slow release; oros Adalat Oros 20 mg PT. Bayer Indonesia blister 2,999.00214 Nifedipin tab 30 mg, oros Adalat Oros 30 mg PT. Bayer Indonesia blister 3,500.00215 Nifedipin tablet/kapsul 10 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet salut selaput 110216 Nistatin tablet salut 500.000 IU/ g n/a PT. Phapros, Tbk Dus @ 10 X 10 's 640217 Noretisteron tablet 5 mg Primolut N PT. Bayer Indonesia blister 2,618.00218 Obat Antituberkulosis FDC Kategori 1 n/a PT. Kimia Farma Paket 359,990.00219 Obat Antituberkulosis FDC Kategori 2 n/a PT. Indofarma Paket 1,199,990.00220 Obat Antituberkulosis FDC Kategori Anak n/a PT. Phapros, Tbk Paket 214,900.00221 Obat Antituberkulosis FDC Sisipan n/a PT. Indofarma Dus, 3 blister @ 28 kss 160,000.00222 Ofloxacin tablet 200 mg n/a PT. Novell Box ,5 Strip @ 10 tablet 400223 Ofloxacin tablet 400 mg n/a PT. Novell Box ,5 Strip @ 10 tablet 650224 Oksimetazolin tetes hidung 0,025% Ilaidin Drops PT. Merck Tbk botol @ 10 ml 27,550.00225 Olanzapin kapl salut 5 mg Olandoz 5 PT. Sandoz Indonesia 3 X 10 fcc 6,450.00226 Olanzapin tab 10 mg Olandoz 10 PT. Sandoz Indonesia 3 X 10 fcc 11,200.00227 Omeprazol injeksi 40 mg/ 10 ml n/a PT. Natura Laboratoria Farma Dus, 1 Vial @ 40 mg 36,000.00228 Omeprazol kapsul/kaplet 20 mg n/a PT. Novapharin strip 211229 ondansetron inj 4 mg/ 2 mL n/a PT. Indofarma Dus, 5 Ampul @ 2ml 2,400.00230 Ondansetron tab 4 mg n/a PT. Yarindo Farmatama Box 3 X 10 Tab 716231 Ondansetron tablet 8 mg n/a PT. Yarindo Farmatama Box 3 X 10 Tab 1,189.00

232Paket CAPD Awal (Komposisi: 1 unit Transfer Set, 2 unit Ultaclam, 1 unit Tenckoff Catheter, Titanium Adaptor)

n/a PT Kalbe Farma

Transfer Set: Set; Ultaclam: Kantong Plastik; Tenckoff Catheter: Box; Titanium Adaptor: Kantong Plastik

1,902,240.00

233 Paket CAPD Pergantian Transfer Set per 6 bulan n/a PT Kalbe Farma Set 219,540.00

234Paket CAPD Rutin 120 ( 4x ganti cairan perhari dengan komposisi Larutan Dialisa 1.5 %, Larutan Dialisa 2.5 %, Larutan Dialisa 4.25 %, Minicap)

Larutan Dialisa 1.5%: Dianeal Low Calcium with 1,5% Dextrose; Larutan Dialisa 2.5%: Dianeal Low Calcium with 2,5% Dextrose; Larutan Dialisa 4.25%: Dianeal Low Calcium with 4.25% Dextrose

PT Kalbe Farma

Larutan Dialisa 1.5 %: 2.000 ml; Larutan Dialisa 2.5 %: 2.000 ml; Larutan Dialisa 4.25 %: 2.000 ml; Minicap: Kantong Plastik

5,522,580.00

235 Parasetamol sirup 120 mg / 5 ml n/a PT. Afifarma botol 60 ml 1,438.00236 Pegylated interferon alfa-2a inj 135 mcg/0,5 ml Pegasys PT. Boehringer Ingelheim Boks, 1 pfs 1,077,815.00237 Pegylated interferon alfa-2a inj 180 mcg/0,5 ml Pegasys PT. Boehringer Ingelheim Boks, 1 pfs 1,248,220.00238 Permetrin krim 5% Scabimite Cream 10 PT. Galenium Tube @ 10 g 11,475.00239 Petidin injeksi i.m/s.k/i.v lambat 50 mg/ml (HCl) n/a PT. Kimia Farma Ktk 10 ampx2ml 14,500.00240 Pioglitazon tab 15 mg DECULIN 15 MG PT. Dexa Medica 30 TAB/BOX 3,120.00241 Pioglitazon tab 30 mg DECULIN 30 MG PT. Dexa Medica 30 TAB/BOX 4,525.00242 Pirantel suspensi 125 mg/5 ml n/a PT. Holi Pharma Botol 60 ml 8,360.00243 Pirantel tablet score (base) 125 mg n/a PT. Holi Pharma Dus, 25 Blister @ 4 tablet 298244 Pirazinamid tablet 500 mg n/a PT. Holi Pharma Dus 10 strip @ 10 tablet 208245 Polikresulen cairan Aptil PT. Pratapa Nirmala Dus, Botol @ 10ml 17,393.00246 Povidon Iodida larutan 10% 1000 ml n/a PT. Afifarma botol @ 1000 ml 37,109.00247 Povidon Iodida larutan 10% 30 ml n/a PT. Afifarma botol @ 30 ml 2,163.00248 Povidon Iodida larutan 10% 300 ml n/a PT. Afifarma botol @ 300 ml 14,203.00249 Pramipeksol tab ER 0,375 mg Sifrol ER 0,375mg PT. Boehringer Ingelheim Dus, 3 alu blister @ 10 tablet 7,200.00250 Pramipeksol tab ER 0,750 mg Sifrol ER 0,750mg PT. Boehringer Ingelheim Dus, 3 alu blister @ 10 tablet 11,268.00251 Pravastatin tablet 20 mg n/a PT. Novell Box ,5 Strip @ 10 tablet 2,300.00252 Propanolol tablet 10 mg ( HCl ) n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 65253 Propranolol tablet 40 mg (HCl) n/a PT. Holi Pharma Dus, 10 strip @ 10 tablet 107254 Ramipril tablet 5 mg n/a PT. Dexa Medica Dus, 3 Strip @ 10 kaptab 580255 Ranitidin injeksi 25 mg/2 ml n/a PT. Natura Laboratoria Farma Dus, 10 Ampul @ 2 ml 1,140.00256 Ranitidin tablet 150 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet salut selaput 120257 Retinol (Vitamin A) 100.000 IU n/a PT. Kimia Farma Botol 50 kapsul lunak 260258 Ringer Laktat larutan infus n/a PT. Widatra Bhakti botol 500 ml 5,200.00259 Risperidon tablet 1 mg n/a PT. Dexa Medica Dus, 5 Blister @ 10 tablet 1,200.00260 Risperidon tablet 2 mg n/a PT. Mersifarma KOTAK @ 5 x 10 TAB 1,008.00261 Risperidon tablet 3 mg n/a PT. Dexa Medica Dus, 5 Blister @ 10 tablet 2,000.00262 Ropinirol Tablet Salut 2 mg Requip PD 24 Hour 2 mg PT. Glaxo Wellcome Indonesia Dus, 7 blister @ 4 Tablet lepas Lambat 5,247.50263 Ropinirol Tablet Salut 4 mg Requip PD 24 Hour 4 mg PT. Glaxo Wellcome Indonesia Dus, 7 blister @ 4 Tablet lepas Lambat 6,275.00264 Ropinirol Tablet Salut 8 mg Requip PD 24 Hour 8 mg PT. Glaxo Wellcome Indonesia Dus, 7 blister @ 4 Tablet lepas Lambat 7,383.33265 Salbutamol inhalasi/aerosol 100 mcg/dosis Ventolin Inhaler PT. Glaxo Wellcome Indonesia Dus, botol 200 dosis 63,750.00266 Salbutamol serb inh 200 mcg/kaps Ventolin Rotacaps PT. Glaxo Wellcome Indonesia Dus, 10 Blister @ 10 Kapsul 430.67267 Salbutamol serb inh 200 mcg/kaps + rotahaler Ventolin Rotahaler PT. Glaxo Wellcome Indonesia Dus, 1 Rotahaler 5,866.67268 Sefadroksil sirup kering 125 mg/5ml n/a PT. Holi Pharma Dus, Botol 60 ml 4,896.00269 Sefadroksil kapsul/kaplet 500 mg n/a PT. Bernofarm Dus, 10 strip @ 10 kapsul 509270 Sefadroksil sir kering 250 mg/5 mL n/a PT. Holi Pharma Dus, Botol 60 ml 5,940.00271 Sefaleksin kapsul/kaplet 500 mg n/a PT. Ifars Dus, 5 Strip @ 10 Kapsul 1,000.00272 Sefepim inj 1 g n/a PT. Yarindo Farmatama Box 2 Vial @ 1000mg 48,060.00273 Sefiksim kapsul/kaplet 100 mg n/a PT. Bernofarm Dus, 10 blister @ 10 kapsul 859274 Sefiksim sirup kering 100 mg/ 5 ml n/a PT. Ifars Dus, Botol 30 ml 8,800.00275 Sefotaksim injeksi 1 g n/a PT. Natura Laboratoria Farma Dus, 10 Vial @ 1 g 2,950.00276 Sefpodoksim proksetil tab 100 mg Banadoz 100 PT. Sandoz Indonesia Dus, 3 blister @ 10 tablet 3,700.00277 Seftriakson serbuk injeksi 1 g/vial n/a PT. Natura Laboratoria Farma Dus, 10 Vial @ 1 g 3,300.00278 Sefuroksim tab 500 mg Zinnat 500 PT. Glaxo Wellcome Indonesia Dus, 1 Blister @ 10 Tablet salut selaput 7,200.00279 Setirizin tablet 10 mg n/a PT. Pertiwi Agung Box, 10 strips @ 10 capsules 181280 Sianokobalamin (vitamin B12) injeksi 500 mcg n/a PT. Lucas Djaja 100 ampul @ 1 ml 1,078.00281 Siklofosfamid serbuk injeksi i.v. 1000 mg Cyclovid 1000 mg PT. Novell vial 256,000.00282 Siklofosfamid serbuk injeksi i.v. 200 mg Cyclovid 200 mg PT. Novell vial 82,000.00283 Simvastatin scored tablet 10 mg n/a PT. Natura Laboratoria Farma Dus, 3 Strip @ 10 Kaplet salut selaput 169284 Simvastatin tablet 20 mg n/a PT. Natura Laboratoria Farma Dus, 3 Strip @ 10 Kaplet salut selaput 391285 Siprofloksasin infus 2% n/a PT. Dexa Medica Vial 200 ml 13,000.00286 Spiramisin tablet 500 mg n/a PT. Indofarma Dus, 5 strip @ 10 tablet 1,499.00287 Spironolakton tablet 100 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 900288 Spironolakton tablet 25 mg n/a PT. Dexa Medica Dus, 10 Strip @ 10 tablet 315289 Sufentanil injeksi iv, epidural 5 mcg/ml Sufentanyl Injeksi iv.Epidural 5 mcg / mlPT. Kimia Farma dus 5 amp @ 2ml 127,000.00290 Takrolimus kaps 0.5 mg Prograf PT. Combiphar Pounch @ 5 blister @ 10 capsule 11,167.00291 Tamsulosin tab 0,2 mg Harnal ® D 0.2 mg Disp. Tablet PT. Combiphar Box/ 2 blister @ 14 tablet 5,800.00292 Tamsulosin tab 0,2 mg Harnal D PT. Combiphar Box @ 2 blister @ 14 tablet 5,800.00293 Tamsulosin tab SR 0,4 mg Harnal ® OCAS 0.4 mg Tablet PT. Combiphar Box/ 3 blister @ 10 Tablet 6,800.00294 Terbutalin tablet 2,5 mg Molasma Tablet PT. Molex Ayus Box 50's 99295 Tetrasiklin kapsul/kaplet 250 mg n/a PT. Holi Pharma Dus, 10 strip @ 10 kapsul 149296 Tiamazol tab 5 mg Thyrozol 5 PT. Merck Tbk Dus, 10 blister @ 10 tablet 563297 Timolol tetes mata 0,25% Isotic Adretor 0,25% PT. Pratapa Nirmala Dus, Botol Plastik @ 5ml 9,128.00298 Timolol tetes mata 0,5% Isotic Adretor 0,5% PT. Pratapa Nirmala Dus, Botol Plastik @ 5ml 9,722.00299 Tiotropium kaps 18 mcg + handihaller Spiriva 10s + Handihaler PT. Boehringer Ingelheim Dus, 1 blister @10 kapsul + handihaler 152,543.00300 Tramadol injeksi 50 mg/ml n/a PT. Natura Laboratoria Farma Dus, 10 Ampul @ 2 ml 2,395.00

No Nama Obat Generik Nama Dagang Nama Penyedia Kemasan Harga Satuan Terkecil (Rp)301 Trifluoperazin tablet 5 mg n/a PT. Darya Varia strip 405302 Urea krim 10% Soft U Derm PT. Galenium tube 6,400.00303 Valproat tab SR 250 mg Depakote ER 250 mg PT. Abbott Indonesia Tablet 2,793.00304 Valproat tab SR 500 mg Depakote ER 500 mg PT. Abbott Indonesia Tablet 5,450.00305 Verapamil tab 240 mg Isoptin 240 mg PT. Abbott Indonesia Tablet 6,200.00306 Verapamil tablet 80 mg (HCl) n/a PT. Kimia Farma Ktk 10X10 TAB 234307 Vinblastin serbuk injeksi 10 mg Vinblastine PT. Combiphar Vial 10mg/10ml 210,000.00308 Zidovudin 300 mg + Lamivudine 150 mg n/a PT. Kimia Farma Botol 60 tablet 3,429.00309 Zinc drop 10 mg/mL Zincpro Drops PT. Combiphar Drops 10 mg/ml, Botol @15 ml 12,840.00310 Zinc sir 20 mg/5 Ml Zircum Kid Sirup PT. Meprofarm Dus, botol 60 ml 7,400.00

311 Zinc tablet dispersible20 mg n/a PT. Indofarma Dus, 10 strip @ 10 tablet dispersible 474

Harga Satuan Terkecil (Rp)