DAFTAR USULAN OBAT BPJS TAHUN 2015.docx

DAFTAR USULAN OBAT BPJS TAHUN 2015PUSKESMAS MANDASTANA

No Nama Satuan Harga Jumlah Permintaan Jumlah Harga Pabrik1 2 3 4 5 6 71 Allopurinol 100 mg Tablet 90 1400 126000 PT. Pertiwi Agung2 Amitriptilin 25 mg Tablet 123 100 12300 PT. Indofarma3 Amoksicilin 500 mg Tablet 279 21000 5859000 PT Mersifarma Tirmacu Mercusana4 Amoksicilin sirup kering 125 mg/ 5 ml Botol 60 ml 2560 500 1280000 PT. Novapharin5 Amoksicilin sirup kering forte 250 mg/ 5 ml Botol 60 ml 4750 700 3325000 PT Holi Pharma6 Antasida DOEN I tablet kunyah Tablet 78 21000 1638000 PT Erela7 Antasida DOEN II suspensi Botol 60 ml 2300 700 1610000 PT Lucas Djaja8 Anti migrain DOEN Tablet 149 2100 312900 PT. Kimia Farma9 Asam Asetilsalisilat (acetosal) 100 mg Tablet 127 300 38100 PT. Phapros Tbk

10 Asam Mefenamat 500 mg Tablet 122 21000 2562000 PT Bernofarm11 Bedak Salisil serbuk 2% Dus 1350 210 283500 PT Rama Emerald Multi Sukses12 Betametason krim 0.1% Tube 1558 210 327180 PT Kimia Farma13 Betametason Tetes Mata 1 mg/ml Botol 5 ml 25106 21 527226 PT Sanbe Farma14 Bisakodil suppositoria 10 mg Supp 6045 105 634725 PT Sanbe Farma15 Deksamethason 0,5 mg Tablet 68 28000 1904000 PT Promedrahardjo Farmasi Industri16 Diazepam 2 mg Tablet 46 700 32200 PT Kimia Farma17 Diazepam larutan rectal 5 mg/2.5 ml Stesolid 12751 7 89257 PT Actavis Indonesia18 Difenhidramin inj i.v/i.m 10 mg/ml (HCl) Ampul 1160 210 243600 PT Lucas Djaja19 Dimenhidrinat 50 mg Tablet 107 700 74900 PT Kimia Farma20 Dinatrium Edetat Tetes mata 0,35% botol 15ml 37500 35 1312500 PT. Cendo Industri Farmasi21 Domperidon suspensi 5 mg/ 5 ml Botol 60 ml 3490 100 349000 PT Novapharin22 Fenoterol HBr ih 100 mcg/puff Canister 10 ml 72900 14 1020600 PT. Boehringer Ingelheim23 Flusinolon asetonid krim 0.025% Tube 2700 210 567000 PT Ifars Pharmaceutical Laboratories24 Gentamisin salep mata 0.3% Tube 3,5 gram 2786 350 975100 PT Erela25 Gentamisin Tetes Mata Botol 5 ml 3513 280 983640 PT. Indofarma26 Gliserin larutan 5% Botol 100 ml 5867 35 205345 PT. Lucas Djaja27 Glukosa 5% larutan infus Botol 500 ml 5720 140 800800 PT. Widarta Bhakti28 Hidrokortison krim 2.5% Tube 5 gram 2868 280 803040 PT. Kimia Farma29 Hiosin Butil Bromid injeksi 20mg/ml Ampul 1ml 4950 35 173250 PT. Otto Pharmaceuticals

30 Ibuprofen sirup 100 mg/ 5 ml Botol 60 ml 3849 700 2694300 PT. Indofarma31 Isosorbid Dinitrat sublingual 5 mg Tablet 98 700 68600 PT. Kimia Farma32 Kaptopril 25 mg Tablet 97 3500 339500 PT. Phapros Tbk33 Ketokonazol krim 2% tube 10 gram 2633 210 552930 PT. Kimia Farma34 Kodein 10 mg Tablet 550 2100 1155000 PT. Kimia Farma35 Kotrimoksazol suspensi 240 mg Botol 60 ml 2298 350 804300 PT. Holy Pharma36 Kuinin 222 mg Tablet 594 300 178200 PT. Kimia Farma37 Lansoprazol 30 mg Kapsul 521 5000 2605000 PT. Indofarma38 Laxadine Emulsi Botol 60 ml 12450 14 174300 PT. Galinium Pharmasia Laboratories39 Lidokain injeksi @%(HCl)+Efinefrin 1:80,000 Ampul 2ml 1499 700 1049300 PT. Indofarma40 Loratadin 10 mg Tablet 170 2100 357000 PT. Promedrahardjo Farmasi Industri41 Metformin HCl 500 mg Tablet 118 2100 247800 PT. Bernofarm42 Metil prednisolon 8 mg Tablet 390 7000 2730000 PT. Dexa Medica43 Metilergometrin Maleat Tablet 169 2100 354900 PT. Kimia Farma44 Metoklopramide sirup 5 mg/5 ml Botol 60 ml 2900 140 406000 PT. Molex Ayus45 Mometason furoat krim 0.1% Tube 10 gram 20048 35 701680 PT. Guardian Pharmatama46 Nacl 0,9% Botol 500 ml 5170 140 723800 PT. Widarta Bhakti47 Natrium Diklofenak 50mg Tablet 193 14000 2702000 PT. Phapros Tbk48 Nifedipin 10mg Tablet 110 2100 231000 PT. Dexa Medica49 Nistatin Vaginal 100.000 IU/g Tablet 528 210 110880 PT. Phapros Tbk50 Oksitosin Injeksi IU 10ml Ampul 1900 350 665000 PT. Tunggal Idaman Abdi51 Omeprazol 20mg Kapsul 221 7000 1547000 PT. Novapharin52 Ondansetron 4mg Tablet 808 2100 1696800 PT. Yarindo Pharma Tama53 Ondansetron Injeksi 4mg/2ml Ampul 2400 35 84000 PT. Indofarma54 Parasetamol 500mg Tablet 88 21000 1848000 PT. Promedrahardjo Farmasi Industri55 Parasetamol Syrup 120mg/5ml Botol 60 ml 1535 700 1074500 PT. Novapharin56 Permetrin Krim 5% Tube 10 gram 11475 35 401625 PT. Galinium Pharmasia Laboratories57 Polikresulen Cairan Botol 10ml 18635 21 391335 PT. Pratapa Nirmala58 Povidon Iodida Larutan 10% Botol 30ml 2344 70 164080 PT. Avi Farma59 Ramipril 5mg Tablet 635 1400 889000 PT. Dexa Medica60 Ranitidin 150mg Tablet 132 7000 924000 PT. Dexa Medica61 Ranitidin Injeksi 25mg/ml Ampul 2ml 1340 210 281400 PT. Natura Laboratoria Prima62 Ringer LaktaT Larutan Infus Botol 500 ml 5720 140 800800 PT. Widarta Bhakti63 Salbutamol Cairan IH 0,1% Vial 2,5ml 7260 70 508200 PT. Glakso Welcome Indonesia

64 Salbutanol 4mg (sebagai Sulfat) Tablet 91 1400 127400 PT. Kimia Farma65 Salep 2/4 Pot 30gram 2200 350 770000 PT. Marin Liza Farmasi66 Sephadroksil 500mg Kapsul 529 7000 3703000 PT. Berno Pharma67 Sephadroksil Syrup Kering 125mg/5ml Botol 60 ml 5286 700 3700200 PT. Holy Pharma68 Setrizin 10mg Kapsul 190 7000 1330000 PT. Pertiwi Agung69 Setrizin Syrup 5mg/5ml Botol 60 ml 8799 140 1231860 PT. Indofarma70 Sianokobalamin Injeksi 500mcg Ampul 1ml 1110 700 777000 PT. Berno Pharma71 Sifrofloksacin 500mg Tablet 265 7000 1855000 PT. Berno Pharma72 Simvastatin 20mg Tablet 480 7000 3360000 PT. Natura Laboratoria Prima73 Simvastatin Scoredn 10mg Tablet 177 7000 1239000 PT. Natura Laboratoria Prima74 Spironolakton 25mg Tablet 350 700 245000 PT. Dexa Medica75 Sukralfat suspensi 500 mg/5 ml Botol 100 ml 14450 210 3034500 PT. Combiphar76 Tetracain HCl tetes mata 0.5% Botol 5 ml 11500 50 575000 PT. Cendo Industri Farmasi77 Timolol Tetes Mata 0,5% Botol 5ml 10286 14 144004 PT. Pratapa Nirmala78 Ambroxol sirup Botol 60 ml 3627 700 2538900

79 Anti Hemaroid DOEN suppKotak 10 Suppositoria 22000 21 462000 PT. Kimia Farma

80 Gliseril Guaiakolat 100 mg Botol 1000 Tablet 30690 7 21483081 Thiamin HCl 50 mg Tablet 83 21000 1743000 PT. Novapharin82 Seterizin 10 mg Tablet 190 7000 133000083 TOTAL 85913087

Mandastana, 5 Februari 2015Kepala Puskesmas Mandastana

Laila Wardani SKMNIP 197407201997032003

DAFTAR USULAN OBAT BPJS TAHUN 2015 (DANA SISA 2014)PUSKESMAS MANDASTANA

No Nama Satuan Harga Jumlah Permintaan Jumlah Harga Pabrik

1 2 3 4 5 6 71 Allopurinol 100 mg Tablet 90 1000 90000 PT. Pertiwi Agung2 Amitriptilin 25 mg Tablet 123 100 12300 PT. Indofarma3 Amoksicilin 500 mg Tablet 279 12000 3348000 PT Mersifarma Tirmacu Mercusana4 Amoksicilin sirup kering 125 mg/ 5 ml Botol 60 ml 2560 400 1024000 PT. Novapharin5 Amoksicilin sirup kering forte 250 mg/ 5 ml Botol 60 ml 4750 500 2375000 PT Holi Pharma6 Antasida DOEN I tablet kunyah Tablet 78 10000 780000 PT Erela7 Antasida DOEN II suspensi Botol 60 ml 2300 500 1150000 PT Lucas Djaja8 Anti migrain DOEN Tablet 149 1500 223500 PT. Kimia Farma9 Asam Asetilsalisilat (acetosal) 100 mg Tablet 127 500 63500 PT. Phapros Tbk

10 Asam Mefenamat 500 mg Tablet 122 15000 1830000 PT Bernofarm11 Bedak Salisil serbuk 2% Dus 1350 150 202500 PT Rama Emerald Multi Sukses12 Betametason krim 0.1% Tube 1558 150 233700 PT Kimia Farma13 Betametason Tetes Mata 1 mg/ml Botol 5 ml 25106 15 376590 PT Sanbe Farma14 Bisakodil suppositoria 10 mg Supp 6045 75 453375 PT Sanbe Farma15 Deksamethason 0,5 mg Tablet 68 20000 1360000 PT Promedrahardjo Farmasi Industri16 Diazepam 2 mg Tablet 46 500 23000 PT Kimia Farma17 Diazepam larutan rectal 5 mg/2.5 ml Stesolid 12751 5 63755 PT Actavis Indonesia18 Difenhidramin inj i.v/i.m 10 mg/ml (HCl) Ampul 1160 150 174000 PT Lucas Djaja19 Dimenhidrinat 50 mg Tablet 107 500 53500 PT Kimia Farma20 Dinatrium Edetat Tetes mata 0,35% botol 15ml 37500 25 937500 PT. Cendo Industri Farmasi21 Domperidon suspensi 5 mg/ 5 ml Botol 60 ml 3490 150 523500 PT Novapharin22 Fenoterol HBr ih 100 mcg/puff Canister 10 ml 72900 10 729000 PT. Boehringer Ingelheim23 Flusinolon asetonid krim 0.025% Tube 2700 150 405000 PT Ifars Pharmaceutical Laboratories24 Gentamisin salep mata 0.3% Tube 3,5 gram 2786 250 696500 PT Erela25 Gentamisin Tetes Mata Botol 5 ml 3513 200 702600 PT. Indofarma26 Gliserin larutan 5% Botol 100 ml 5867 25 146675 PT. Lucas Djaja27 Glukosa 5% larutan infus Botol 500 ml 5720 50 286000 PT. Widarta Bhakti28 Hidrokortison krim 2.5% Tube 5 gram 2868 200 573600 PT. Kimia Farma29 Hiosin Butil Bromid injeksi 20mg/ml Ampul 1ml 4950 25 123750 PT. Otto Pharmaceuticals30 Ibuprofen sirup 100 mg/ 5 ml Botol 60 ml 3849 500 1924500 PT. Indofarma31 Isosorbid Dinitrat sublingual 5 mg Tablet 98 300 29400 PT. Kimia Farma32 Kaptopril 25 mg Tablet 97 2500 242500 PT. Phapros Tbk33 Ketokonazol krim 2% tube 10 gram 2633 150 394950 PT. Kimia Farma

34 Kodein 10 mg Tablet 550 1000 550000 PT. Kimia Farma35 Kotrimoksazol suspensi 240 mg Botol 60 ml 2298 250 574500 PT. Holy Pharma36 Kuinin 222 mg Tablet 594 500 297000 PT. Kimia Farma37 Lansoprazol 30 mg Kapsul 521 5000 2605000 PT. Indofarma38 Laxadine Emulsi Botol 60 ml 12450 10 124500 PT. Galinium Pharmasia Laboratories39 Lidokain injeksi @%(HCl)+Efinefrin 1:80,000 Ampul 2ml 1499 500 749500 PT. Indofarma40 Loratadin 10 mg Tablet 170 1500 255000 PT. Promedrahardjo Farmasi Industri41 Metformin HCl 500 mg Tablet 118 1500 177000 PT. Bernofarm42 Metil prednisolon 8 mg Tablet 390 5000 1950000 PT. Dexa Medica43 Metilergometrin Maleat Tablet 169 1500 253500 PT. Kimia Farma44 Metoklopramide sirup 5 mg/5 ml Botol 60 ml 2900 100 290000 PT. Molex Ayus45 Mometason furoat krim 0.1% Tube 10 gram 20048 25 501200 PT. Guardian Pharmatama46 Nacl 0,9% Botol 500 ml 5170 50 258500 PT. Widarta Bhakti47 Natrium Diklofenak 50mg Tablet 193 10000 1930000 PT. Phapros Tbk48 Nifedipin 10mg Tablet 110 1500 165000 PT. Dexa Medica49 Nistatin Vaginal 100.000 IU/g Tablet 528 150 79200 PT. Phapros Tbk50 Oksitosin Injeksi IU 10ml Ampul 1900 250 475000 PT. Tunggal Idaman Abdi51 Omeprazol 20mg Kapsul 221 5000 1105000 PT. Novapharin52 Ondansetron 4mg Tablet 808 1000 808000 PT. Yarindo Pharma Tama53 Ondansetron Injeksi 4mg/2ml Ampul 2400 25 60000 PT. Indofarma54 Parasetamol 500mg Tablet 88 12500 1100000 PT. Promedrahardjo Farmasi Industri55 Parasetamol Syrup 120mg/5ml Botol 60 ml 1535 500 767500 PT. Novapharin56 Permetrin Krim 5% Tube 10 gram 11475 25 286875 PT. Galinium Pharmasia Laboratories57 Polikresulen Cairan Botol 10ml 18635 15 279525 PT. Pratapa Nirmala58 Povidon Iodida Larutan 10% Botol 30ml 2344 50 117200 PT. Avi Farma59 Ramipril 5mg Tablet 635 1000 635000 PT. Dexa Medica60 Ranitidin 150mg Tablet 132 5000 660000 PT. Dexa Medica61 Ranitidin Injeksi 25mg/ml Ampul 2ml 1340 100 134000 PT. Natura Laboratoria Prima62 Ringer LaktaT Larutan Infus Botol 500 ml 5720 50 286000 PT. Widarta Bhakti63 Salbutamol Cairan IH 0,1% Vial 2,5ml 7260 25 181500 PT. Glakso Welcome Indonesia64 Salbutanol 4mg (sebagai Sulfat) Tablet 91 1000 91000 PT. Kimia Farma65 Salep 2/4 Pot 30gram 2200 200 440000 PT. Marin Liza Farmasi66 Sephadroksil 500mg Kapsul 529 5000 2645000 PT. Berno Pharma67 Sephadroksil Syrup Kering 125mg/5ml Botol 60 ml 5286 500 2643000 PT. Holy Pharma

68 Setrizin 10mg Kapsul 190 5000 950000 PT. Pertiwi Agung69 Setrizin Syrup 5mg/5ml Botol 60 ml 8799 100 879900 PT. Indofarma70 Sianokobalamin Injeksi 500mcg Ampul 1ml 1110 400 444000 PT. Berno Pharma71 Sifrofloksacin 500mg Tablet 265 4000 1060000 PT. Berno Pharma72 Simvastatin 20mg Tablet 480 5000 2400000 PT. Natura Laboratoria Prima73 Simvastatin Scoredn 10mg Tablet 177 5000 885000 PT. Natura Laboratoria Prima74 Spironolakton 25mg Tablet 350 500 175000 PT. Dexa Medica75 Sukralfat suspensi 500 mg/5 ml Botol 100 ml 14450 100 1445000 PT. Combiphar76 Tetracain HCl tetes mata 0.5% Botol 5 ml 11500 25 287500 PT. Cendo Industri Farmasi77 Timolol Tetes Mata 0,5% Botol 5ml 10286 10 102860 PT. Pratapa Nirmala78 Ambroxol sirup Botol 60 ml 3627 300 1088100


80 Gliseril Guaiakolat 100 mg Botol 1000 Tablet 30690 5 15345081 Thiamin HCl 50 mg Tablet 83 10000 830000 PT. Novapharin82 Seterizin 10 mg Tablet 190 5000 950000

TOTAL 57007505



DAFTAR USULAN BAHAN MEDIS HABIS PAKAI BPJS TAHUN 2015PUSKESMAS MANDASTANA

No Nama Satuan Harga Jumlah Permintaan Jumlah Harga Merk1 2 3 4 5 6 71 Aquadest Botol 1 ltr 15730 1 15730 Pan Chemistr2 Bayclin Botol 1 ltr 27500 1 27500

3 Benang plan 3/0 pcs 9075 24 217800 OM/GEA/Seremity4 Catgut chromic 3/0 box 24 pcs 217800 1 217800 OM/GEA/Seremity5 Etil klorida semprot botol 137500 5 687500 Water Ritcher6 Kasa hidrofil 4x15 cm box 50 roll 151250 1 151250 OM7 Kasa steril 16/16 Box 10 pcs 7865 30 235950 OM8 Reagen golongan darah A Vial 84700 5 423500 Onemed9 reagen golongan darah B Vial 84700 5 423500 Onemed

10 Stik Asam Urat box 110000 30 3300000 Easy touch/Nessco11 Stik gula darah box 110000 30 3300000 Easy touch/Nessco12 Stik kolesterol box 192500 30 5775000 Easy touch/Nessco13 Tes Kehamilan box 50 88000 1 88000 OM14 U pad 60x90 steril w/SAP pak isi 10 66550 10 665500 OM15 Urinbag pcs 4901 20 98020 Urocare16 IV Catheter No 20 box isi 24 389375 1 389375 OM/Sterra17 IV Catheter No 22 box isi 24 389375 1 389375 OM/Sterra18 IV Catheter No 24 box isi 24 389375 1 389375 OM/Sterra19 Alat suntik 1 ml box 109250 5 546250 OM/Sterra20 Alat suntik 2.5 ml box 103800 10 1038000 OM/Sterra21 Alat suntik 5 ml box 103800 5 519000 OM/Sterra22 Sarung Tangan No 7 box isi 50 212500 5 1062500 Serenity/MPM23 Sarung Tangan No 7.5 box isi 50 212500 5 1062500 Serenity/MPM24 Sarung Tangan No 8 box isi 50 212500 5 1062500 Serenity/MPM25 Alvogyl 10 gr botol 583000 1 583000 Septodont, France26 Arsen 6.5 gr pot 390000 1 390000 Septodont, France27 Glass Ionomer sement (Fuji IX) set 395000 1 395000 GC, Japan28 Kalsium Hidroksida pasta set 242000 1 242000 Dorident, Austria29 Composite A2, 3.8 gr tube 550000 1 550000 Tokuyama, Jepang30 Composite A3, 3.8 gr tube 550000 1 550000 Tokuyama, Jepang31 Bonding Single Bond botol 1100000 1 1100000 DMG, Germany32 Etching botol 330000 1 330000 Meta, Korea33 Kuas Bonding box 170500 1 170500 MicroBrush

34 Vitrebond/ base = bonding ktk/btl 352000 1 352000Master Bond, Biodinamika

35 Cavit (tumpahan sementara) 30 gr pot 166980 1 166980 Dorident, Austria36 Cresophate botol 836000 1 836000 Septodont, France

37 Cresophene botol 902000 1 902000 Septodont, France38 Iodoform pasta botol 297000 1 297000 Ghimas, Italy39 Spongostan box/50 steril 525000 1 525000 Curaspon, Netderland40 Zinc phosphat semen set 176000 1 176000 Dorident, Austria

TOTAL 29651405



DAFTAR USULAN BAHAN MEDIS HABIS PAKAI BPJS TAHUN 2015 (DANA SISA 2014)PUSKESMAS MANDASTANA

No Nama Satuan Harga Jumlah Permintaan Jumlah Harga Merk1 2 3 4 5 6 71 Reagen golongan darah A Vial 84700 2 169400 Onemed2 reagen golongan darah B Vial 84700 2 169400 Onemed3 Stik Asam Urat box 110000 3 330000 Easy touch/Nessco4 Stik gula darah box 110000 3 330000 Easy touch/Nessco5 Stik kolesterol box 192500 3 577500 Easy touch/Nessco

6 Sarung Tangan No 7 box isi 50 212500 1 212500 Serenity/MPM7 Sarung Tangan No 7.5 box isi 50 212500 2 425000 Serenity/MPM8 Sarung Tangan No 8 box isi 50 212500 1 212500 Serenity/MPM9 Alvogyl 10 gr botol 583000 1 583000 Septodont, France

10 Arsen 6.5 gr pot 390000 1 390000 Septodont, France11 Glass Ionomer sement (Fuji IX) set 395000 1 395000 GC, Japan12 Kalsium Hidroksida pasta set 242000 1 242000 Dorident, Austria13 Composite A2, 3.8 gr tube 550000 1 550000 Tokuyama, Jepang14 Composite A3, 3.8 gr tube 550000 1 550000 Tokuyama, Jepang15 Bonding Single Bond botol 1100000 1 1100000 DMG, Germany16 Etching botol 330000 1 330000 Meta, Korea17 Kuas Bonding box 170500 1 170500 MicroBrush18 Vitrebond/ base = bonding ktk/btl 352000 1 352000 Master Bond, Biodinamika19 Cavit (tumpahan sementara) 30 gr pot 166980 1 166980 Dorident, Austria20 Cresophate botol 836000 1 836000 Septodont, France21 Cresophene botol 902000 1 902000 Septodont, France22 Iodoform pasta botol 297000 1 297000 Ghimas, Italy23 Spongostan box/50 steril 525000 1 525000 Curaspon, Netderland24 Zinc phosphat semen set 176000 1 176000 Dorident, Austria

TOTAL 9991780Mandastana, 5 Februari 2015Kepala Puskesmas Mandastana


DAFTAR USULAN OBAT BPJS TRIWULAN I TAHUN 2015PUSKESMAS MANDASTANA

No Nama Satuan Harga Perencanaan 3 bulan Harga 3 bulan Pabrik1 2 3 4 5 6 71 Allopurinol 100 mg Tablet 90 300 27000 PT. Pertiwi Agung2 Amitriptilin 25 mg Tablet 123 100 12300 PT. Indofarma3 Amoksicilin 500 mg Tablet 279 5200 1450800 PT Mersifarma Tirmacu Mercusana4 Amoksicilin sirup kering 125 mg/ 5 ml Botol 60 ml 2560 100 256000 PT. Novapharin5 Amoksicilin sirup kering forte 250 mg/ 5 Botol 60 ml 4750 200 950000 PT Holi Pharma

ml6 Antasida DOEN I tablet kunyah Tablet 78 5000 390000 PT Erela7 Antasida DOEN II suspensi Botol 60 ml 2300 150 345000 PT Lucas Djaja8 Anti migrain DOEN Tablet 149 500 74500 PT. Kimia Farma9 Asam Asetilsalisilat (acetosal) 100 mg Tablet 127 100 12700 PT. Phapros Tbk

10 Asam Mefenamat 500 mg Tablet 122 5000 610000 PT Bernofarm11 Bedak Salisil serbuk 2% Dus 1350 50 67500 PT Rama Emerald Multi Sukses12 Betametason krim 0.1% Tube 1558 50 77900 PT Kimia Farma13 Betametason Tetes Mata 1 mg/ml Botol 5 ml 25106 5 125530 PT Sanbe Farma14 Bisakodil suppositoria 10 mg Supp 6045 20 120900 PT Sanbe Farma15 Deksamethason 0,5 mg Tablet 68 7000 476000 PT Promedrahardjo Farmasi Industri16 Diazepam 2 mg Tablet 46 200 9200 PT Kimia Farma17 Diazepam larutan rectal 5 mg/2.5 ml Stesolid 12751 5 63755 PT Actavis Indonesia18 Difenhidramin inj i.v/i.m 10 mg/ml (HCl) Ampul 1160 30 34800 PT Lucas Djaja19 Dimenhidrinat 50 mg Tablet 107 100 10700 PT Kimia Farma20 Dinatrium Edetat Tetes mata 0,35% botol 15ml 37500 10 375000 PT. Cendo Industri Farmasi21 Domperidon suspensi 5 mg/ 5 ml Botol 60 ml 3490 50 174500 PT Novapharin22 Fenoterol HBr ih 100 mcg/puff Canister 10 ml 72900 0 0 PT. Boehringer Ingelheim23 Flusinolon asetonid krim 0.025% Tube 2700 50 135000 PT Ifars Pharmaceutical Laboratories24 Gentamisin salep mata 0.3% Tube 3,5 gram 2786 80 222880 PT Erela25 Gentamisin Tetes Mata Botol 5 ml 3513 70 245910 PT. Indofarma26 Gliserin larutan 5% Botol 100 ml 5867 10 58670 PT. Lucas Djaja27 Glukosa 5% larutan infus Botol 500 ml 5720 40 228800 PT. Widarta Bhakti28 Hidrokortison krim 2.5% Tube 5 gram 2868 72 206496 PT. Kimia Farma29 Hiosin Butil Bromid injeksi 20mg/ml Ampul 1ml 4950 5 24750 PT. Otto Pharmaceuticals30 Ibuprofen sirup 100 mg/ 5 ml Botol 60 ml 3849 200 769800 PT. Indofarma31 Isosorbid Dinitrat sublingual 5 mg Tablet 98 200 19600 PT. Kimia Farma32 Kaptopril 25 mg Tablet 97 800 77600 PT. Phapros Tbk33 Ketokonazol krim 2% tube 10 gram 2633 50 131650 PT. Kimia Farma34 Kodein 10 mg Tablet 550 500 275000 PT. Kimia Farma35 Kotrimoksazol suspensi 240 mg Botol 60 ml 2298 100 229800 PT. Holy Pharma36 Kuinin 222 mg Tablet 594 100 59400 PT. Kimia Farma37 Lansoprazol 30 mg Kapsul 521 1260 656460 PT. Indofarma

38 Laxadine Emulsi Botol 60 ml 12450 3 37350 PT. Galinium Pharmasia Laboratories

39 Lidokain injeksi @%(HCl)+Efinefrin 1:80,000 Ampul 2ml 1499 200 299800 PT. Indofarma

40 Loratadin 10 mg Tablet 170 500 85000 PT. Promedrahardjo Farmasi Industri41 Metformin HCl 500 mg Tablet 118 500 59000 PT. Bernofarm42 Metil prednisolon 8 mg Tablet 390 1700 663000 PT. Dexa Medica43 Metilergometrin Maleat Tablet 169 500 84500 PT. Kimia Farma44 Metoklopramide sirup 5 mg/5 ml Botol 60 ml 2900 50 145000 PT. Molex Ayus45 Mometason furoat krim 0.1% Tube 10 gram 20048 10 200480 PT. Guardian Pharmatama46 Nacl 0,9% Botol 500 ml 5170 20 103400 PT. Widarta Bhakti47 Natrium Diklofenak 50mg Tablet 193 3500 675500 PT. Phapros Tbk48 Nifedipin 10mg Tablet 110 500 55000 PT. Dexa Medica49 Nistatin Vaginal 100.000 IU/g Tablet 528 100 52800 PT. Phapros Tbk50 Oksitosin Injeksi IU 10ml Ampul 1900 90 171000 PT. Tunggal Idaman Abdi51 Omeprazol 20mg Kapsul 221 1760 388960 PT. Novapharin54 Parasetamol 500mg Tablet 88 5200 457600 PT. Promedrahardjo Farmasi Industri55 Parasetamol Syrup 120mg/5ml Botol 60 ml 1535 200 307000 PT. Novapharin56 Permetrin Krim 5% Tube 10 gram 11475 8 91800 PT. Galinium Pharmasia Laboratories57 Polikresulen Cairan Botol 10ml 18635 5 93175 PT. Pratapa Nirmala58 Povidon Iodida Larutan 10% Botol 30ml 2344 17 39848 PT. Avi Farma59 Ramipril 5mg Tablet 635 350 222250 PT. Dexa Medica60 Ranitidin 150mg Tablet 132 1700 224400 PT. Dexa Medica61 Ranitidin Injeksi 25mg/ml Ampul 2ml 1340 50 67000 PT. Natura Laboratoria Prima62 Ringer LaktaT Larutan Infus Botol 500 ml 5720 40 228800 PT. Widarta Bhakti63 Salbutamol Cairan IH 0,1% Vial 2,5ml 7260 17 123420 PT. Glakso Welcome Indonesia64 Salbutanol 4mg (sebagai Sulfat) Tablet 91 300 27300 PT. Kimia Farma65 Salep 2/4 Pot 30gram 2200 100 220000 PT. Marin Liza Farmasi66 Sephadroksil 500mg Kapsul 529 1700 899300 PT. Berno Pharma67 Sephadroksil Syrup Kering 125mg/5ml Botol 60 ml 5286 150 792900 PT. Holy Pharma68 Setrizin 10mg Kapsul 190 1700 323000 PT. Pertiwi Agung69 Setrizin Syrup 5mg/5ml Botol 60 ml 8799 50 439950 PT. Indofarma70 Sianokobalamin Injeksi 500mcg Ampul 1ml 1110 200 222000 PT. Berno Pharma71 Sifrofloksacin 500mg Tablet 265 1700 450500 PT. Berno Pharma

72 Simvastatin 20mg Tablet 480 1700 816000 PT. Natura Laboratoria Prima73 Simvastatin Scoredn 10mg Tablet 177 1700 300900 PT. Natura Laboratoria Prima74 Spironolakton 25mg Tablet 350 200 70000 PT. Dexa Medica75 Sukralfat suspensi 500 mg/5 ml Botol 100 ml 14450 50 722500 PT. Combiphar76 Tetracain HCl tetes mata 0.5% Botol 5 ml 11500 10 115000 PT. Cendo Industri Farmasi77 Timolol Tetes Mata 0,5% Botol 5ml 10286 10 102860 PT. Pratapa Nirmala78 Ambroxol sirup Botol 60 ml 3627 100 362700

79 Anti Hemaroid DOEN supp Kotak 10 Suppositoria 22000 6 132000 PT. Kimia Farma

80 Gliseril Guaiakolat 100 mg Botol 1000 Tablet 30690 2 6138081 Thiamin HCl 50 mg Tablet 83 5000 415000 PT. Novapharin82 Seterizin 10 mg Tablet 190 1700 32300083 TOTAL 20.678.274

DAFTAR USULAN BAHAN MEDIS HABIS PAKAI BPJS TRIWULAN I TAHUN 2015PUSKESMAS MANDASTANA

No Nama Satuan Harga Perencanaan 3 bulan Harga 3 bulan Merk

1 2 3 4 71 Aquadest Botol 1 ltr 15730 0 Pan Chemistr2 Bayclin Botol 1 ltr 27500 03 Benang plan 3/0 pcs 9075 0 OM/GEA/Seremity4 Catgut chromic 3/0 box 24 pcs 217800 0 OM/GEA/Seremity5 Etil klorida semprot botol 137500 0 Water Ritcher6 Kasa hidrofil 4x15 cm box 50 roll 151250 0 OM7 Kasa steril 16/16 Box 10 pcs 7865 0 OM8 Reagen golongan darah A Vial 84700 0 Onemed9 reagen golongan darah B Vial 84700 0 Onemed

10 Stik Asam Urat box 110000 9 990000 Easy touch/Nessco11 Stik gula darah box 110000 9 990000 Easy touch/Nessco12 Stik kolesterol box 192500 9 1732500 Easy touch/Nessco13 Tes Kehamilan box 50 88000 0 OM14 U pad 60x90 steril w/SAP pak isi 10 66550 0 OM15 Urinbag pcs 4901 0 Urocare16 IV Catheter No 20 box isi 24 389375 0 0 OM/Sterra17 IV Catheter No 22 box isi 24 389375 0 0 OM/Sterra18 IV Catheter No 24 box isi 24 389375 0 OM/Sterra19 Alat suntik 1 ml box 109250 0 OM/Sterra20 Alat suntik 2.5 ml box 103800 0 0 OM/Sterra21 Alat suntik 5 ml box 103800 0 OM/Sterra22 Sarung Tangan No 7 box isi 50 212500 0 Serenity/MPM23 Sarung Tangan No 7.5 box isi 50 212500 0 Serenity/MPM24 Sarung Tangan No 8 box isi 50 212500 0 Serenity/MPM25 Alvogyl 10 gr botol 583000 1 583000 Septodont, France26 Arsen 6.5 gr pot 390000 0 0 Septodont, France27 Glass Ionomer sement (Fuji IX) set 395000 0 0 GC, Japan28 Kalsium Hidroksida pasta set 242000 0 0 Dorident, Austria29 Composite A2, 3.8 gr tube 550000 1 550000 Tokuyama, Jepang30 Composite A3, 3.8 gr tube 550000 0 0 Tokuyama, Jepang

31 Bonding Single Bond botol 1100000 0 0 DMG, Germany

32 Etching botol 330000 1 330000 Meta, Korea33 Kuas Bonding box 170500 0 0 MicroBrush

34 Vitrebond/ base = bonding ktk/btl 352000 1 352000 Master Bond, Biodinamika

35 Cavit (tumpahan sementara) 30 gr pot 166980 1 166980 Dorident, Austria36 Cresophate botol 836000 1 836000 Septodont, France37 Cresophene botol 902000 0 0 Septodont, France38 Iodoform pasta botol 297000 1 297000 Ghimas, Italy39 Spongostan box/50 steril 525000 1 525000 Curaspon, Netderland40 Zinc phosphat semen set 176000 1 176000 Dorident, Austria

TOTAL 7528480



DAFTAR USULAN OBAT PKD TAHUN 2015PUSKESMAS MANDASTANA

No Nama Satuan Harga Jumlah Permintaan Jumlah Harga Pabrik1 2 3 4 5 6 71 Asiklovir salep mata Tube 24750 100 2475000 PT Sanbe Farma2 Allopurinol 100 mg Tablet 90 1400 126000 PT. Pertiwi Agung3 Ambroxol sirup Botol 60 ml 3627 700 2538900 PT Kimia Farma4 Aminophilin 200 mg Tablet 86 500 43000 PT Erela5 Amitriptilin 25 mg Tablet 123 100 12300 PT. Indofarma6 Amoksicilin 500 mg Tablet 279 24000 6696000 PT Mersifarma Tirmacu Mercusana7 Amoksicilin sirup kering 125 mg/ 5 ml Botol 60 ml 2560 500 1280000 PT. Novapharin8 Amoksicilin sirup kering forte 250 mg/ 5 ml Botol 60 ml 4750 700 3325000 PT Holi Pharma9 Amoksilin 250 mg Kapsul 220 10000 2200000 PT Indofarma

10 Antasida DOEN I tablet kunyah Tablet 78 21000 1638000 PT Erela

11 Antasida DOEN II suspensi Botol 60 ml 2300 700 1610000 PT Lucas Djaja


13 Anti migrain DOEN Tablet 149 2100 312900 PT. Kimia Farma14 Asam Asetilsalisilat (acetosal) 100 mg Tablet 127 300 38100 PT. Phapros Tbk15 Asam askorbat 50 mg Tablet 105 24000 2520000 PT Kimia farma16 Asam folat 1 mg Tablet 52 600 31200 PT Marlin Liza17 Asam Mefenamat 500 mg Tablet 122 21000 2562000 PT Bernofarm18 Asam traneksamat inj Ampul 3650 24 87600 Pt Hexpharm19 Asiklovir 200 mg Tablet 245 1200 294000 Pt Kimia farma20 Asiklovir 400mg Tablet 345 6000 2070000 Pt Kimia farma21 Attalpugit Tablet 220 6000 1320000 Pt Zenith22 Betahistin 240023 Bedak Salisil serbuk 2% Dus 1350 210 283500 PT Rama Emerald Multi Sukses24 Betametason krim 0.1% Tube 1558 210 327180 PT Kimia Farma25 Betametason Tetes Mata 1 mg/ml Botol 5 ml 25106 21 527226 PT Sanbe Farma26 Bisakodil suppositoria 10 mg Supp 6045 105 634725 PT Sanbe Farma27 Deksamethason 0,5 mg Tablet 68 48000 3264000 PT Promedrahardjo Farmasi Industri28 Dexametason injeksi Ampul 1738 1200 2085600 Pt Indofarma29 Diazepam 2 mg Tablet 46 700 32200 PT Kimia Farma30 Diazepam larutan rectal 5 mg/2.5 ml Stesolid 12751 12 153012 PT Actavis Indonesia31 Difenhidramin inj i.v/i.m 10 mg/ml (HCl) Ampul 1160 480 556800 PT Lucas Djaja32 Digoksin 0,25 mg Tablet 103 600 61800 Pt Yarindo33 Dimenhidrinat 50 mg Tablet 107 700 74900 PT Kimia Farma34 Dinatrium Edetat Tetes mata 0,35% botol 15ml 37500 35 1312500 PT. Cendo Industri Farmasi35 Domperidon suspensi 5 mg/ 5 ml Botol 60 ml 3490 100 349000 PT Novapharin36 Epineprin injeksi Ampul 8910 100 891000 Pt Phapros37 Eritromisin 500mg Tablet 1023 5000 5115000 Pt Kimia farma38 Etanol 70 % cairan Botol 1 liter 2625 36 94500 Pt Novapharin39 Eugenol cairan Botol 18333 1 18333 Pt Kimia farma40 Fenoterol HBr ih 100 mcg/puff Canister 10 ml 72900 14 1020600 PT. Boehringer Ingelheim41 Fitomenadion Injeksi Ampul 3754 600 2252400 Pt Phapros42 Fitomenadion tablet Tablet 698 2400 1675200 Pt Marlin Liza43 Flusinolon asetonid krim 0.025% Tube 2700 210 567000 PT Ifars Pharmaceutical Laboratories44 Furosemid 200 mg Tablet 84 1000 84000 Pt sampharindo

45 Garam oralit Bungkus 317 2000 634000 Pt Phapros46 Gentamisin salep mata 0.3% Tube 3,5 gram 2786 350 975100 PT Erela47 Gentamisin Tetes Mata Botol 5 ml 3513 280 983640 PT. Indofarma48 Gliseril Guaiakolat 100 mg Botol 1000 Tablet 30690 24 73656049 Gliserin larutan 5% Botol 100 ml 5867 35 205345 PT. Lucas Djaja50 Glukosa 5% larutan infus Botol 500 ml 5720 140 800800 PT. Widarta Bhakti51 Griseofulvin 125mg Tablet 224 1200 268800 Pt Kimia farma52 Haloperidol 0,5 mg Tablet 62 300 18600 Pt Indofarma53 Hidrokortison krim 2.5% Tube 5 gram 2868 280 803040 PT. Kimia Farma54 Hiosin Butil Bromid injeksi 20mg/ml Ampul 1ml 4950 35 173250 PT. Otto Pharmaceuticals55 Ibuprofen 200mg Tablet 121 1000 121000 Pt Yarindo56 Ibuprofen 400mg Tablet 157 3000 471000 Pt Novapharin57 Ibuprofen sirup 100 mg/ 5 ml Botol 60 ml 3849 700 2694300 PT. Indofarma58 Isosorbid Dinitrat sublingual 5 mg Tablet 98 700 68600 PT. Kimia Farma59 Kaptopril 12,5mg Tablet 69 1000 69000 Pt Indofarma60 Kaptopril 25 mg Tablet 97 3500 339500 PT. Phapros Tbk61 Karbamazepin 200mg Tablet 269 300 80700 Pt Indofarma62 Ketokonazol 200mg Tablet 320 600 192000 Pt Novapharin63 Ketokonazol krim 2% tube 10 gram 2633 210 552930 PT. Kimia Farma64 Klorampenikol 250mg Kapsul 275 1200 330000 Pt Phapros65 Klorampenikol salep Tube 1640 50 82000 Pt Kimia farma66 Kodein 10 mg Tablet 550 2100 1155000 PT. Kimia Farma67 Kotrimoksazol suspensi 240 mg Botol 60 ml 2298 350 804300 PT. Holy Pharma68 Kotrimoksazol 480 mg Tablet 152 6000 912000 Pt Promedhardjo69 Kuinin 222 mg Tablet 594 300 178200 PT. Kimia Farma70 Lansoprazol 30 mg Kapsul 521 5000 2605000 PT. Indofarma71 Laxadine Emulsi Botol 60 ml 12450 14 174300 PT. Galinium Pharmasia Laboratories72 Lidocain jelly Tube 40000 50 2000000 Pt Astra73 Lidokain injeksi @%(HCl)+Efinefrin 1:80,000 Ampul 2ml 1499 700 1049300 PT. Indofarma74 lisinopril 10mg Tablet 660 600 396000 Pt Novell75 Lisinopril 5mg Tablet 385 600 231000 Pt Novell76 Loperamid Tablet 97 1000 97000 Pt Ifars77 Loratadin 10 mg Tablet 170 2100 357000 PT. Promedrahardjo Farmasi Industri78 Metformin HCl 500 mg Tablet 118 2100 247800 PT. Bernofarm

79 Metil prednisolon 8 mg Tablet 390 7000 2730000 PT. Dexa Medica80 Metilergometrin Maleat Tablet 169 2100 354900 PT. Kimia Farma81 Metoklopramide 10mg Tablet 100 1000 100000 Pt Phapros82 Metoklopramide drop Botol 5830 100 583000 Pt Memproparm83 Metoklopramide sirup 5 mg/5 ml Botol 60 ml 2900 200 580000 PT. Molex Ayus84 Metronidazol 250mg Tablet 116 1000 116000 Pt phyto85 Metronidazol 500mg Tablet 169 6000 1014000 Pt Phyto86 Mikonazol cream Tube 3075 600 1845000 Pt Kimia farma87 Mometason furoat krim 0.1% Tube 10 gram 20048 60 1202880 PT. Guardian Pharmatama88 Nacl 0,9% Botol 500 ml 5170 140 723800 PT. Widarta Bhakti89 Natrium Diklofenak 50mg Tablet 193 14000 2702000 PT. Phapros Tbk90 Nifedipin 10mg Tablet 110 2100 231000 PT. Dexa Medica91 Nistatin 500.000 Tablet 704 1000 704000 Pt phapros92 Nistatin Vaginal 100.000 IU/g Tablet 528 600 316800 PT. Phapros Tbk93 Obat Tuberkulosis kategori 1 FDC Paket 395900 15 5938500 Pt Phapros94 Obat Tuberkulosis kategori 2 FDC Paket 1319990 0 Pt Indofarma95 Oksitosin Injeksi IU 10ml Ampul 1900 350 665000 PT. Tunggal Idaman Abdi96 Omeprazol 20mg Kapsul 221 7000 1547000 PT. Novapharin97 Ondansetron 4mg Tablet 808 2100 1696800 PT. Yarindo Pharma Tama98 Ondansetron Injeksi 4mg/2ml Ampul 2400 35 84000 PT. Indofarma99 Parasetamol 500mg Tablet 88 21000 1848000 PT. Promedrahardjo Farmasi Industri

100 Parasetamol drop Botol 5720 100 572000 Pt Indofarma101 Parasetamol Syrup 120mg/5ml Botol 60 ml 1535 1200 1842000 PT. Novapharin102 Permetrin Krim 5% Tube 10 gram 11475 35 401625 PT. Galinium Pharmasia Laboratories103 Polikresulen Cairan Botol 10ml 18635 36 670860 PT. Pratapa Nirmala104 Povidon iodida Larutan 10% Botol 300 ml 15386 10 153860 PT. Afi Farma105 Povidon Iodida Larutan 10% Botol 30ml 2344 70 164080 PT. Afi Farma106 Propanolol 40mg Tablet 80 300 24000 Pt holi farma107 ProfilThio Urasil Tablet 351 300 105300 Pt Indofarma108 Pyrantel Pamoat Tablet 318 0 0 Pt holi farma109 Ramipril 5mg Tablet 635 1400 889000 PT. Dexa Medica110 Ranitidin 150mg Tablet 132 7000 924000 PT. Dexa Medica111 Ranitidin Injeksi 25mg/ml Ampul 2ml 1340 210 281400 PT. Natura Laboratoria Prima112 Ringer LaktaT Larutan Infus Botol 500 ml 5720 140 800800 PT. Widarta Bhakti

113 Salbutamol 2mg Tablet 65 3600 234000 Pt Yarindo114 Salbutamol Cairan IH 0,1% Vial 2,5ml 7260 70 508200 PT. Glakso Welcome Indonesia115 Salbutanol 4mg (sebagai Sulfat) Tablet 91 3600 327600 PT. Kimia Farma116 Salep 2/4 Pot 30gram 2200 360 792000 PT. Marin Liza Farmasi117 Sefotaxim 1 gr Vial 3500 5 17500 Pt Natura118 Seftriaxon 1 gr Vial 3700 5 18500 Pt dexa medica119 Sephadroksil 500mg Kapsul 529 7000 3703000 PT. Berno Pharma120 Sephadroksil Syrup Kering 125mg/5ml Botol 60 ml 5286 700 3700200 PT. Holy Pharma121 Setrizin 10mg Kapsul 190 7000 1330000 PT. Pertiwi Agung122 Setrizin Syrup 5mg/5ml Botol 60 ml 8799 140 1231860 PT. Indofarma123 Sianokobalamin Injeksi 500mcg Ampul 1ml 1110 700 777000 PT. Berno Pharma124 Siprofloksacin 500mg Tablet 265 7000 1855000 PT. Berno Pharma125 Simvastatin 20mg Tablet 480 7000 3360000 PT. Natura Laboratoria Prima126 Simvastatin Scoredn 10mg Tablet 177 7000 1239000 PT. Natura Laboratoria Prima127 Spironolakton 25mg Tablet 350 700 245000 PT. Dexa Medica128 Sukralfat suspensi 500 mg/5 ml Botol 100 ml 14450 210 3034500 PT. Combiphar129 Tablet Tambah Darah Bungkus @30 2400 PT Kimia Farma130 Tetracain HCl tetes mata 0.5% Botol 5 ml 11500 50 575000 PT. Cendo Industri Farmasi131 Tetrasiklin 500mg Kapsul 325 600 195000 Pt Afifarma132 Thiamin HCl 50 mg Tablet 83 21000 1743000 PT. Novapharin133 Timolol Tetes Mata 0,5% Botol 5ml 10286 14 144004 PT. Pratapa Nirmala134 Vitamin b komplek Tablet 112 6000 672000 Pt Kimia farma135 zinc drop 10mg/ml Botol 14160 50 708000 Pt combiphar136 Zinc sirup Botol 8140 60 488400 Pt meprofarm137 Zinc 10 mg Tablet 521 1200 625200 Pt Indofarma


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