1 2 3 4

NAMA UNIT :
BULAN :
A. OBAT- OBATAN
1 Albendazole 400 mg
2 Alopurinol 100 mg
3 Alprazolam 1 mg
4 Ambroxol 30 mg
5 Ambroxol Sirup 15 mg/ 5ml
6 Aminophilin 200 mg
7 Aminophillin Injeksi 24 mg/ml
8 Amitriptilina Tab 25 mg
9 Amlodipin 5 mg
10 Amoksisilin 500 mg
11 Amoksisilin Sirup Kering 125 mg/5ml
12 Ampisilin Injeksi 1 gram
13 Antasida Doen I Tablet Kunyah
14 Antasida Doen II Suspensi
15 Anti Bakteri Doen Salep Kombinasi
16 Anti Haemoroid DOEN Kombinasi (Superhoid)
17 Aqua Pro Injeksi Steril bebas pirogen
18 Artemeter Injeksi
19 Artesunate Injeksi
20 Asam Asetilsalisilat (Asetosal) 100 mg
21 Asam Askorbat 50 mg
22 Asam Folat 0,4 mcg
23 Asam Mefenamat 500 mg
24 Asiklovir 400 mg
25 Asiklovir Krim (Lacyvir)
26 Atapulgit 600 mg (New Antides)
27 Atropin Sulfat Injeksi 0,2 mg/ml
28 Azitromisin 500 mg
29 Bedak Salisil Serbuk 2%
30 Betametason Krim 0,1%
31 Bisakodil 10 mg Suppositoria
32 Bisakodil 5 mg Suppositoria
33 Camabion
34 Caviplex
35 Cefotaxim Injeksi
36 Combivent UDV
37 Deksametason 0,5 mg
38 Deksametason Injeksi 5 mg/ml
39 Devitalisasi Pasta Non Arsen
40 Diazepam Enema 5 mg/2,5 ml (Stesolid)
41 Diazepam Inj 5 mg/ml 2ml
42 Diazepam tablet 2 mg
43 Difenhidramine Injeksi 10 mg/ml Hcl
44 Digoksin 0,25 mg
45 Doksisiklin 100 mg
46 Epinefrin (Adrenalin) Injeksi1 mg/ml (0,1%)
47 Etabion
48 Etakridin (Rivanol) Lar 0,1 %
49 Etil Klorida Semprot
50 Eugenol Cairan
51 Famotidin 40 mg (Pratifar)
52 Fenobarbital 30 mg
53 Fenobarbital Injeksi 50 mg/ml
54 Fenol Gliserol TT 10 %
55 Fitomenadion (Vit. K1) 10 mg
56 Fitomenadion Inj 10 mg/ml
57 Furosemid 40 mg
58 Furosemid Injeksi
59 Garam Oralit 200 ml
60 Gentamicin
61 Gentian Violet Lar 1 %
62 Glass Ionomer Cemen (GCIX)
63 Glibenclamid Tab 5 mg (Trodeb))
64 Glukosa Infus 10 %
65 Glukosa Infus 40 %
66 Glukosa Larutan Infus 5%
67 Guaifenesin Tab 100 mg
68 Haloperidol 5 mg
69 Hidrokortison Krim 2,5%
70 Ibuprofen 400 mg
71 Ibuprofen Suspensi 100 mg/5ml
72 Isosorbid Dinitrat 5 mg
73 Kalsium Gluconat Injeksi 100 mg
74 Kalsium Hidroksida Pasta
75 Kalsium Laktat
76 Kaptopril 12,5 mg
77 Kaptopril 25 mg
78 Karbamazepin 200 mg
79 Ketokonazole 200 mg
80 Ketoprofen Injeksi
81 Kloramfenikol 250 mg
82 Kloramfenikol 500 mg (Chloramex)
83 Kloramfenikol SM 1 %
84 Kloramfenikol Suspensi 125 mg/5 ml
85 Kloramfenikol TM 0,5%
86 Klorampenikol TT 3 %
87 Klorfeniramina Maleat (CTM) 4 mg
88 Klorpromazina100 mg
89 Kotrimoksazole 480 mg
90 Kotrimoksazole Suspensi
91 Kuinin Dihidroksida Injeksi 25 %
92 Kuinin Sulfat 222 mg
93 Larutan KDN1 500 ML
94 Lidokain Hcl Injeksi 2%
95 Lidokain Kompositum Injeksi
96 Lodomer Injeksi
97 Magnesium Sulfat Inj(IV) 40 %
98 Metformin 500 mg
100 Metilergometrin Maleat Injeksi 0,2 mg /ml
101 Metilergometrin Maleat tab 0,125 mg
103 Metoklopramid 5 mg
104 Metoklopramid Injeksi 5 mg/ml
105 Metoklopramide Sirup 5 mg/5 ml
106 Metoklopramide10 mg
107 Metronidazol 500 mg
108 Mikonazol Krim 2%
109 Mumifaying Pasta
110 Chlor Phenol Kamfer Menthol
111 Natrium Diklofenak 50 mg
112 Natrium Klorida 0.9%
113 Neodin10% 300 ml (Afifarma)
114 Nifedipin 10 mg
115 Nistatin 500.000 IU/G
116 Oat FDC Anak
117 OAT FDC I
118 Oat FDC II
119 Obat Anti Malaria ( Arterakin )
120 OBH Cairan
121 Oksitetrasikli SM 1 %
122 Oksitetrasiklin HCl Inj 50 mg/ml 10 ml
123 Oksitetrasilin SK 3 %
124 Oksitosin Injeksi
125 Paracetamol drop 60 mg/0.6 ml (Fasidol)
126 Parasetamol 500 mg
127 Parasetamol Rectal
128 Parasetamol Sirup 120 mg/5 ml
129 Pehacain Injeksi
130 Piridoksin (Vit. B6) 10 mg (Hcl)
131 Piroxicam10 mg
132 Prednison 5 mg
133 Primakuin15 mg
134 Prokain Benzil Penisilin Inj 3 Juta IU/vial
135 Propanolol 40 mg
136 Propil Tio Urasil100 mg
137 Ranitidin 150 mg
138 Ranitidin Injeksi 25 mg/ml
139 Retinol (Vit. A) Kapsul Lunak 100.000 IU
140 Retinol (Vit. A) Kapsul Lunak 200.000 IU
141 Ringer Laktat
142 Risperidon
143 Sabu Polivalen 5 ml (ABU I)
144 Salbutamol 2 mg
145 Salbutamol 4 mg
146 Salep 24
147 Sefiksim 100 mg
148 Semen Seng Posfat
149 Serum ATS 1500 IU / Ampul
150 Sianokobalamin Injeksi (Vit. B12) 500 MCG
151 Silver Amalgam
152 Simvastatin 10 mg
153 Siprofloksasin 500 mg
154 Skizonoat Injeksi
155 Tablet Tambah Darah Fero Fumarat 60 mg + Asam
Folat 0,4 mg
156 Temporary Stopping Fletcher Serbuk

157 Thiamin Hcl (Vit B1) Inj 100 mg/ml

158 Tiamin (Vit. B1) 50 mg
159 Triheksipenidil 2 mg
160 Trikresolformalin (TKF) Cairan
161 Ventolin Nebulizer
162 Vitamin B Kompleks
163 Zinc 20 mg
164 Zink Sirup 10 mg/ml

B. VAKSIN
1 HBU
2 DPT HB HIB
3 BCG
4 POLIO ( OPV )
5 IPV
6 CAMPAK
7 TD

C. PERBEKALAN KESEHATAN
1 Alkohol 70% 1000 ml (Afifarma)
2 Catgut Chromic 3/0 with needle
3 Catgut Plain 3/0 with needle
6 Infus Set Anak
7 Infus Set Dewasa
 8 IV Catheter 18G X 1-1/4"
9 IV Catheter 20G X 1-1/4"
10 IV Catheter 22G X 1"
11 IV Catheter 24G X 3/4"
12 Jarum Suntik
13 Kapas Pembalut 250 gram
14 Kasa Hidrofile 3 yard X 15 cm
15 Kasa Hidrofile 40 yard X 80 cm
16 Kasa Pembalut 4 Yard x 15 cm
17 Masker
23 Plester Rol Kain 5 cm X 4,5 m
24 Plester Transparant
25 Sarung Tangan Non Steril
26 Sarung Tangan Obgin Steril No. 6,5
27 Sarung Tangan Obgin Steril No. 7,0
28 Sarung Tangan Steril No. 6,5
29 Sarung Tangan Steril No. 7,0
30 Sarung Tangan Steril No. 7,5
31 Silk 3/0 with needle
34 Spuit 1 cc tb
35 Spuit 3 cc
36 Spuit 5 cc
37 Spuit 10 cc
D. TAMBAHAN
T-1 Foley Catheter 20
T-2 Softpad (Under Pad)
T-3 umblical clem
T-4 Urine Bag Sterile
T-5 Nasal Oksigen Bayi
T-6 Nasal Oksigen Anak
T-7 Nasal Oksigen Dewasa
T-8 PP INH
T-9 Glimepirid
T-10 Acetylcystein 200 mg
T-11 Sefadroxil syrup
T-12 Ketorolac Inj
T-13 Plesterin bulat soft
T-14 WIDABES
T-15 Spalk
T-16 Xylocain spray 10%
T-17 Kombipak azithromycin cefixime
T-18 Cetirizin 10 mg
T-19 Methylprednisolon 4 mg
T-20 Ondansetron inj
T-21 Ibuprofen 200mg
T-22 Kombipa FDC I
 T-23 Bayclin lar pemutih
T-24 Omeprazole 20 mg
T-25 Foley Catheter 18
T-26 Cefotaxime inj 1gr
T-27 Ketoprofen supp
T-28 Aminophilin 150 mg
T-29 Parasetamol infus
T-30 sarung tangan non steril S
T-31 sarung tangan non steril M
T-32 sarung tangan non steril L
T-33 tranexamat acid inj 5%
T-34 Amoxicilin drop
T-35 ceterizin syr
T-36 Klozapin tab
T-37 Sucralfat syr
II. JAMINAN KESEHATAN NASIONAL
1 Aminofilin inj 24 mg/ml
2 Amlodipin tablet/kapsul/kaplet 5 mg
3 Amoksisilin kapsul/kaplet/tablet scored 500 mg
4 amoxisilin 500 (novamox)
5 Amoksisilin sirup kering 125 mg/5 ml
6 Anti Bakteri DOEN Salep Kombinasi
7 Aqua pro injeksi
8 Asam asetilsalisilat (asetosal) 100 mg
9 Asam Mefenamat
10 Asiklovir 400 mg
11 Asiklovir Cream
12 Attapulgit
13 Bedak salisil serbuk 2%
14 Betahistin tablet/kapsul/kaplet 6 mg
15 Bisakodil tablet/kapsul/kaplet 5 mg
16 (Chlor Phenol Kamper Menthol (CHKM) 10 ml
Champenol)

17 Cavit 28 gr (Bahan untuk tumpatan sementara)

18 Devitalisasi Pasta Non Arsen
19 Deksametason Injeksi
20 Deksametason 0,5 mg (faridexon)
21 Dextrose 40%
22 Diazepam tab (stesolid)
23 Diazepam inj (stesolid)
24 Dipenhidramin
25 Domperidon 10 mg
26 Domperidon Sirup
27 Etil Klorida Semprot 100 ml Spray
28 Fitomenadion (Vit K1) 10 mg
29 Fitomenadion inj.
GENERIK Amoksisilin sirup kering forte 250 mg/ 5
30 ml

31 GENERIK Glimepiride tablet/kapsul/kaplet 2 mg

32 Gentamicin inj
Glass Ionomer Cemen ( Powder 15gr,Liquid 8gr
33 (6.4ml))
34 Griseofulfin Tab 125 mg
35 Hyoscine-N-butylbromide 10 mg
36 Hyoscine-N-butylbromide 20 mg/ml Injeksi
37 Hidrocortison sk
38 Kalsium Glukonat inj i.v 10%
39 Kalsium Hidroksida Pasta (Hydcal)
40 Kalsium Laktat (LIKOKALK)
41 Kaptopril tablet/ 50 mg
42 ketokonazole SK
43 Ketorolak inji 30 mg/ml
44 Klindamisin tablet/kapsul/kaplet 300 mg
45 Klorfeniramina Maleat 4 mg (CTM)
46 Klorfeniramina Maleat 4 mg (CTM) 2016
47 Kloramfenikol tetes mata 0,5%
48 kloramfenikol SM
49 kloramfenikol kapsul 250mg (microtina)
50 Klorpromazin 100 mg
51 kotrimoxazole D
52 Lidokain inj.
53 Loperamid tablet/kapsul/kaplet 2 mg
54 Metformin HCl tablet/kapsul/kaplet 500 mg
55 Metilergometrin maleat Tab 0,125 mg
56 Metilprednisolon tablet/kapsul/kaplet 4 mg
57 Metoklopramide sirup 5 mg/ 5 ml
58 Metoklopramide tablet/kapsul/kaplet 10 mg
59 MGSO4 40 Magnesium sulfat Injeksi 40%
60 Multivitamin (Betafort Sirup)
61 Multivitamin (Caviplex syrup)
62 Multivitamin (Livron B plex)
63 Mumifaying pasta ( Cresotin Paste)
64 Natrium diklofenak tablet/kapsul/kaplet 50 mg
65 Natrium klorida Infus 0,9%
66 NEODIN 10 % 300 ml
NEUROBION (Vit.B1 100 mg, vit B6 100 mg, vit
67 B12 5.000 mcg) 3ml Injeksi
68 Oksimetazolin tetes hidung 0,025%
69 Oksimetazolin tetes hidung 0,050%
70 Omeprazol tablet/kapsul/kaplet 20 mg
71 Ondansetron inj 2 mg/ml (4 mg/ 2 mL)
72 Oxitocin inj.
73 Papaverin Tablet
74 Parasetamol drips (infus) 1000 mg/100ml
75 Parasetamol sirup 120 mg / 5 ml
76 Parasetamol Tab 500 mg
77 Piracetam 800 mg
78 Piridoksin HCL Tab 10mg ( vitamin B6)
79 Piroxicam (ROSIC)
80 Prednison Tab 5 mg
81 Ranitidin 150 mg
82 Ranitidin Injeksi 25 mg/ml
83 Ringer Laktat
84 Salbutamol 2 mg (Grafalin 2 mg)
85 Salbutamol 4 mg
Salep 2-4, kombinasi: asam salisilat 2% + belerang
86 endap 4%
87 Sefadroksil sirup kering 125 mg/5 ml
88 Sefadroksil tablet/kapsul/kaplet 500 mg
89 Setirizin sirup 5 mg/5 ml
90 Setirizin tablet/kapsul/kaplet 10 mg
91 Siprofloxasin 500 mg
92 Trikresol Formalin 10 ml
93 L-Bio Sachet
94 Vitamin B Kompleks tablet (novabcomp)
95 Zinc Tablet 20 mg
96 Salon pas jet spray
97 Furosemida 40 mg
98 Alprazolam 0,5 mg
99 Parasetamol infus
100 Ketopropen supp
101 Sucralfat susp 500mg/5ml
102 Asam tranexsamat injeksi 50mg/ml
103 Domperidon tablet 10 mg
104 Ondansetron inj 2mg/ml
105 Ketokonazole 200 mg
106 Domperidon syr 5mg/5ml
107 Amoksisilin sirup 250 mg
108
109
B. PERBEKALAN KESEHATAN
1 Infus Set Anak
2 IV Catheter 18G X 1-1/4"
3 IV Catheter 20G X 1-1/4"
 4 IV Catheter 22G X 1"
5 IV Catheter 24G X 3/4"
6 AXIMED FACK MASK TIES ON
7 Sarung Tangan Non Steril Ukuran L
8 Sarung Tangan Non Steril Ukuran M
9 Infus Set Dewasa
10 Sarung Tangan Steril Ukuran 6,5
11 Sarung Tangan Steril Ukuran 7,0
12 Sarung Tangan Steril Ukuran 7,5
13 NASAL OXYGEN, O2 cannula, size XS (Bayi)
14 NASAL OXYGEN, O2 cannula, size S (Anak)
15 NASAL OXYGEN, O2 cannula, size M (Dewasa)
16 Kasa Hidrofile 40 yard x 80 cm
17 Kasa Hidrofile 3 yard x 15 cm (PACK/50 pc)
Spuit 1 cc (NIPRO Syringe 1cc Tuberculin with
18 Needle 26GX1/2" E Beam Sterilization)

Spuit 3 cc (NIPRO Syringe 3cc Luer Lock With

19 Needle 23GX1-1/4" Elektron Beam Sterilization)

Spuit 5 cc (NIPRO Syringe 5cc Luer Lock With

20 Needle 22GX1-1/2" Elektron Beam Sterilization)

Spuit 10 cc (NIPRO Syringe 10cc Luer Lock With

21 Needle 21GX1-1/2" Elektron Beam Sterilization)

22 Silk 3/0 + Jarum 1/2 GT 35 mm

23 Kapas Pembalut 250g
24 Masker N95
25 Urine Bag Sterile
26 My Jelly 82 gram
27 My Jelly 5 gram steril
28 Sabun Aseptic Gel 500 cc + dispenser
29 Sabun Anti Bakteri 500 ml + disp
30 Onemed Asept 500 ml
31 Odex 500 ml
32 Aseptan 500 cc + pump
33 Onescrub 2% 100 ml
34 Onescrub 500 cc + dispenser
35 Onescrub 5 liter
36 Softpad (Underpad) 60 x 90 cm Non Steril
37 USG Gel 250 ml
38 USG Gel 5 L
39 Sarung Tangan Obgyn Steril ( Obgyn glove)
40 Alkohol 70% 1000 ml
41 Twist Blood Lancet
42 Alcohol Swab
43 Benang Operasi Plain Catgut With Needle 3.0
44 Benang Operasi Cromic Catgut With Needle 3.0
45 Foley Catether 2 Way Fr. 18 (Box/10pcs)
46 Foley Catether 2 Way Fr. 20 (Box/10pcs)
47 Plester Rol Kain 5 cm x 4.5 m
48 Gelang Pasien (Merah muda)
49 Gelang Pasien (Biru)
50 Gelang Pasien (Kuning)
51 Masker Nebulizer Anak
52 Masker Nebulizer Dewasa
53 Chlorin 1000 ml
54 Jarum Suntik 23 G
55 Kertas Puyer 500 Lembar
56 Klip Obat Sablon Besar
57 Klip Obat Sablon Kecil
58 Klip Obat Sablon Sedang
59 Steril Scapel Blades No.11
60 Pembersih Lantai 800 ml Refill
61 Perhidrol ( H2O2 ) 3% 1000 ml
62 Spalk First Aid
63 Tissu 250 sheet
64 Spiritus 1000 ml
65 Pengharum Ruangan 250 ml
66 Klem Tali Pusar

1 JAYAMAS Onemed Catgut Plain 3/0 + Jarum 1/2

GT35 mm
2 JAYAMAS Onemed Catgut Chromic 3/0 + jarum
1/2 GT 35 mm
3 JAYAMAS Onemed My Jelly 5 gram steril
4
JAYAMAS Onemed Aseptic Gel 500 cc + dispenser
5
JAYAMAS Onemed OneScrub 500 cc + dispenser
6 JAYAMAS Onemed OneScrub 5 liter
7 JAYAMAS Onemed USG Gel 250ml
8 JAYAMAS Onemed USG Gel 5L
9 JAYAMAS Onemed Lysol 1 Liter
10 JAYAMAS Onemed Surgical Mask Plus 3 Ply Plus
Earloop
11 Aximed EXAMINATION GLOVES, size S
12 Aximed STOMACH TUBE, 85cm, no. 18
13 Aximed FEEDING TUBE, 100cm, no. 8
14 Aximed FEEDING TUBE, 40cm, no. 8
15 Kertas Puyer 500 Lembar
16 Klip Obat Sablon Besar
17 Klip Obat Sablon Sedang
18 Steril Scapel Blades No.11
19 Pembersih Lantai 800 ml Refill
20 Perhidrol ( H2O2 ) 3% 1000 ml
21 Spalk First Aid
22 Pengharum Ruangan 250 ml refill matic
23 Bahan Pengharum ruangan
24 Tisue gulung
25 Kertas USG
26 kantong puyer
27 Kartu gol darah
28 Maternity Softex
29 Tabung EDTA
30 Jarum Vacutainer
31
32
5 6 7 8 9 10 11 12 13
14 15 16 17 18 19 20 21 22
23 24 25 26 27 28 29 30 31
TOTAL

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 14 15 16 17
NAMA UNIT :
BULAN :
A. OBAT- OBATAN
1 Albendazole 400 mg
2 Alopurinol 100 mg 100
3 Alprazolam 1 mg
4 Ambroxol 30 mg 200
5 Ambroxol Sirup 15 mg/ 5ml
6 Aminophilin 200 mg
7 Aminophillin Injeksi 24 mg/ml
8 Amitriptilina Tab 25 mg
9 Amlodipin 5 mg 300
10 Amoksisilin 500 mg 200
11 Amoksisilin Sirup Kering 125 mg/5ml
12 Ampisilin Injeksi 1 gram
13 Antasida Doen I Tablet Kunyah 200
14 Antasida Doen II Suspensi
15 Anti Bakteri Doen Salep Kombinasi
16 Anti Haemoroid DOEN Kombinasi (Superhoid)
17 Aqua Pro Injeksi Steril bebas pirogen
18 Artemeter Injeksi
19 Artesunate Injeksi
20 Asam Asetilsalisilat (Asetosal) 100 mg
21 Asam Askorbat 50 mg 200
22 Asam Folat 0,4 mcg
23 Asam Mefenamat 500 mg 200
24 Asiklovir 400 mg
25 Asiklovir Krim (Lacyvir)
26 Atapulgit 600 mg (New Antides)
27 Atropin Sulfat Injeksi 0,2 mg/ml
28 Azitromisin 500 mg
29 Bedak Salisil Serbuk 2%
30 Betametason Krim 0,1%
31 Bisakodil 10 mg Suppositoria
32 Bisakodil 5 mg Suppositoria
33 Camabion
34 Caviplex
35 Cefotaxim Injeksi
36 Combivent UDV 20
37 Deksametason 0,5 mg 200
38 Deksametason Injeksi 5 mg/ml 30
39 Devitalisasi Pasta Non Arsen
40 Diazepam Enema 5 mg/2,5 ml (Stesolid)
41 Diazepam Inj 5 mg/ml 2ml
42 Diazepam tablet 2 mg
43 Difenhidramine Injeksi 10 mg/ml Hcl
44 Digoksin 0,25 mg
45 Doksisiklin 100 mg
46 Epinefrin (Adrenalin) Injeksi1 mg/ml (0,1%)
47 Etabion
48 Etakridin (Rivanol) Lar 0,1 %
49 Etil Klorida Semprot
50 Eugenol Cairan
51 Famotidin 40 mg (Pratifar)
52 Fenobarbital 30 mg
53 Fenobarbital Injeksi 50 mg/ml
54 Fenol Gliserol TT 10 %
55 Fitomenadion (Vit. K1) 10 mg
56 Fitomenadion Inj 10 mg/ml
57 Furosemid 40 mg
58 Furosemid Injeksi
59 Garam Oralit 200 ml
60 Gentamicin
61 Gentian Violet Lar 1 %
62 Glass Ionomer Cemen (GCIX)
63 Glibenclamid Tab 5 mg (Trodeb)) 200
64 Glukosa Infus 10 %
65 Glukosa Infus 40 %
66 Glukosa Larutan Infus 5%
67 Guaifenesin Tab 100 mg
68 Haloperidol 5 mg
69 Hidrokortison Krim 2,5%
70 Ibuprofen 400 mg
71 Ibuprofen Suspensi 100 mg/5ml
72 Isosorbid Dinitrat 5 mg
73 Kalsium Gluconat Injeksi 100 mg
74 Kalsium Hidroksida Pasta
75 Kalsium Laktat
76 Kaptopril 12,5 mg
77 Kaptopril 25 mg 200
78 Karbamazepin 200 mg
79 Ketokonazole 200 mg
80 Ketoprofen Injeksi
81 Kloramfenikol 250 mg
82 Kloramfenikol 500 mg (Chloramex)
83 Kloramfenikol SM 1 %
84 Kloramfenikol Suspensi 125 mg/5 ml
85 Kloramfenikol TM 0,5%
86 Klorampenikol TT 3 %
87 Klorfeniramina Maleat (CTM) 4 mg 200
88 Klorpromazina100 mg
89 Kotrimoksazole 480 mg 200
90 Kotrimoksazole Suspensi
91 Kuinin Dihidroksida Injeksi 25 %
92 Kuinin Sulfat 222 mg
93 Larutan KDN1 500 ML
94 Lidokain Hcl Injeksi 2%
95 Lidokain Kompositum Injeksi 30
96 Lodomer Injeksi
97 Magnesium Sulfat Inj(IV) 40 %
98 Metformin 500 mg
100 Metilergometrin Maleat Injeksi 0,2 mg /ml
101 Metilergometrin Maleat tab 0,125 mg
103 Metoklopramid 5 mg
104 Metoklopramid Injeksi 5 mg/ml
105 Metoklopramide Sirup 5 mg/5 ml
106 Metoklopramide10 mg
107 Metronidazol 500 mg
108 Mikonazol Krim 2%
109 Mumifaying Pasta
110 Chlor Phenol Kamfer Menthol
111 Natrium Diklofenak 50 mg 200
112 Natrium Klorida 0.9%
113 Neodin10% 300 ml (Afifarma)
114 Nifedipin 10 mg
115 Nistatin 500.000 IU/G
116 Oat FDC Anak
117 OAT FDC I
118 Oat FDC II
119 Obat Anti Malaria ( Arterakin )
120 OBH Cairan
121 Oksitetrasikli SM 1 %
122 Oksitetrasiklin HCl Inj 50 mg/ml 10 ml
123 Oksitetrasilin SK 3 %
124 Oksitosin Injeksi
125 Paracetamol drop 60 mg/0.6 ml (Fasidol)
126 Parasetamol 500 mg 200
127 Parasetamol Rectal
128 Parasetamol Sirup 120 mg/5 ml
129 Pehacain Injeksi
130 Piridoksin (Vit. B6) 10 mg (Hcl) 200
131 Piroxicam10 mg
132 Prednison 5 mg
133 Primakuin15 mg
134 Prokain Benzil Penisilin Inj 3 Juta IU/vial
135 Propanolol 40 mg
136 Propil Tio Urasil100 mg
137 Ranitidin 150 mg 200
138 Ranitidin Injeksi 25 mg/ml 100
139 Retinol (Vit. A) Kapsul Lunak 100.000 IU
140 Retinol (Vit. A) Kapsul Lunak 200.000 IU
141 Ringer Laktat
142 Risperidon
143 Sabu Polivalen 5 ml (ABU I)
144 Salbutamol 2 mg 200
145 Salbutamol 4 mg
146 Salep 24
147 Sefiksim 100 mg 60
148 Semen Seng Posfat
149 Serum ATS 1500 IU / Ampul
150 Sianokobalamin Injeksi (Vit. B12) 500 MCG
151 Silver Amalgam
152 Simvastatin 10 mg 60
153 Siprofloksasin 500 mg
154 Skizonoat Injeksi
155 Tablet Tambah Darah Fero Fumarat 60 mg + Asam
Folat 0,4 mg
156 Temporary Stopping Fletcher Serbuk

157 Thiamin Hcl (Vit B1) Inj 100 mg/ml

158 Tiamin (Vit. B1) 50 mg 200
159 Triheksipenidil 2 mg
160 Trikresolformalin (TKF) Cairan
161 Ventolin Nebulizer
162 Vitamin B Kompleks
163 Zinc 20 mg
164 Zink Sirup 10 mg/ml

B. VAKSIN
1 HBU
2 DPT HB HIB
3 BCG
4 POLIO ( OPV )
5 IPV
6 CAMPAK
7 TD

C. PERBEKALAN KESEHATAN
1 Alkohol 70% 1000 ml (Afifarma)
2 Catgut Chromic 3/0 with needle
3 Catgut Plain 3/0 with needle
6 Infus Set Anak
7 Infus Set Dewasa
 8 IV Catheter 18G X 1-1/4"
9 IV Catheter 20G X 1-1/4"
10 IV Catheter 22G X 1"
11 IV Catheter 24G X 3/4"
12 Jarum Suntik
13 Kapas Pembalut 250 gram
14 Kasa Hidrofile 3 yard X 15 cm
15 Kasa Hidrofile 40 yard X 80 cm
16 Kasa Pembalut 4 Yard x 15 cm
17 Masker
23 Plester Rol Kain 5 cm X 4,5 m
24 Plester Transparant
25 Sarung Tangan Non Steril
26 Sarung Tangan Obgin Steril No. 6,5
27 Sarung Tangan Obgin Steril No. 7,0
28 Sarung Tangan Steril No. 6,5
29 Sarung Tangan Steril No. 7,0
30 Sarung Tangan Steril No. 7,5
31 Silk 3/0 with needle
34 Spuit 1 cc tb
35 Spuit 3 cc
36 Spuit 5 cc
37 Spuit 10 cc
D. TAMBAHAN
T-1 Foley Catheter 20
T-2 Softpad (Under Pad)
T-3 umblical clem
T-4 Urine Bag Sterile
T-5 Nasal Oksigen Bayi
T-6 Nasal Oksigen Anak
T-7 Nasal Oksigen Dewasa
T-8 PP INH
T-9 Glimepirid
T-10 Acetylcystein 200 mg 180
T-11 Sefadroxil syrup
T-12 Ketorolac Inj 100
T-13 Plesterin bulat soft
T-14 WIDABES
T-15 Spalk
T-16 Xylocain spray 10%
T-17 Kombipak azithromycin cefixime
T-18 Cetirizin 10 mg 200
T-19 Methylprednisolon 4 mg
T-20 Ondansetron inj
T-21 Ibuprofen 200mg
T-22 Kombipa FDC I
 T-23 Bayclin lar pemutih
T-24 Omeprazole 20 mg
T-25 Foley Catheter 18
T-26 Cefotaxime inj 1gr 30
T-27 Ketoprofen supp
T-28 Aminophilin 150 mg
T-29 Parasetamol infus
T-30 sarung tangan non steril S
T-31 sarung tangan non steril M
T-32 sarung tangan non steril L
T-33 tranexamat acid inj 5%
T-34 Amoxicilin drop
T-35 ceterizin syr
T-36 Klozapin tab
T-37 Sucralfat syr
II. JAMINAN KESEHATAN NASIONAL
1 Aminofilin inj 24 mg/ml
2 Amlodipin tablet/kapsul/kaplet 5 mg
3 Amoksisilin kapsul/kaplet/tablet scored 500 mg
4 amoxisilin 500 (novamox)
5 Amoksisilin sirup kering 125 mg/5 ml
6 Anti Bakteri DOEN Salep Kombinasi
7 Aqua pro injeksi
8 Asam asetilsalisilat (asetosal) 100 mg
9 Asam Mefenamat
10 Asiklovir 400 mg
11 Asiklovir Cream
12 Attapulgit
13 Bedak salisil serbuk 2%
14 Betahistin tablet/kapsul/kaplet 6 mg
15 Bisakodil tablet/kapsul/kaplet 5 mg
16 (Chlor Phenol Kamper Menthol (CHKM) 10 ml
Champenol)

17 Cavit 28 gr (Bahan untuk tumpatan sementara)

18 Devitalisasi Pasta Non Arsen
19 Deksametason Injeksi
20 Deksametason 0,5 mg (faridexon)
21 Dextrose 40%
22 Diazepam tab (stesolid)
23 Diazepam inj (stesolid)
24 Dipenhidramin
25 Domperidon 10 mg
26 Domperidon Sirup
27 Etil Klorida Semprot 100 ml Spray
28 Fitomenadion (Vit K1) 10 mg
29 Fitomenadion inj.
GENERIK Amoksisilin sirup kering forte 250 mg/ 5
30 ml

31 GENERIK Glimepiride tablet/kapsul/kaplet 2 mg

32 Gentamicin inj
Glass Ionomer Cemen ( Powder 15gr,Liquid 8gr
33 (6.4ml))
34 Griseofulfin Tab 125 mg
35 Hyoscine-N-butylbromide 10 mg
36 Hyoscine-N-butylbromide 20 mg/ml Injeksi
37 Hidrocortison sk
38 Kalsium Glukonat inj i.v 10%
39 Kalsium Hidroksida Pasta (Hydcal)
40 Kalsium Laktat (LIKOKALK)
41 Kaptopril tablet/ 50 mg
42 ketokonazole SK
43 Ketorolak inji 30 mg/ml
44 Klindamisin tablet/kapsul/kaplet 300 mg
45 Klorfeniramina Maleat 4 mg (CTM)
46 Klorfeniramina Maleat 4 mg (CTM) 2016
47 Kloramfenikol tetes mata 0,5%
48 kloramfenikol SM
49 kloramfenikol kapsul 250mg (microtina)
50 Klorpromazin 100 mg
51 kotrimoxazole D
52 Lidokain inj.
53 Loperamid tablet/kapsul/kaplet 2 mg
54 Metformin HCl tablet/kapsul/kaplet 500 mg
55 Metilergometrin maleat Tab 0,125 mg
56 Metilprednisolon tablet/kapsul/kaplet 4 mg
57 Metoklopramide sirup 5 mg/ 5 ml
58 Metoklopramide tablet/kapsul/kaplet 10 mg
59 MGSO4 40 Magnesium sulfat Injeksi 40%
60 Multivitamin (Betafort Sirup)
61 Multivitamin (Caviplex syrup)
62 Multivitamin (Livron B plex)
63 Mumifaying pasta ( Cresotin Paste)
64 Natrium diklofenak tablet/kapsul/kaplet 50 mg
65 Natrium klorida Infus 0,9%
66 NEODIN 10 % 300 ml
NEUROBION (Vit.B1 100 mg, vit B6 100 mg, vit
67 B12 5.000 mcg) 3ml Injeksi
68 Oksimetazolin tetes hidung 0,025%
69 Oksimetazolin tetes hidung 0,050%
70 Omeprazol tablet/kapsul/kaplet 20 mg
71 Ondansetron inj 2 mg/ml (4 mg/ 2 mL) 45
72 Oxitocin inj.
73 Papaverin Tablet
74 Parasetamol drips (infus) 1000 mg/100ml
75 Parasetamol sirup 120 mg / 5 ml
76 Parasetamol Tab 500 mg
77 Piracetam 800 mg
78 Piridoksin HCL Tab 10mg ( vitamin B6)
79 Piroxicam (ROSIC)
80 Prednison Tab 5 mg
81 Ranitidin 150 mg
82 Ranitidin Injeksi 25 mg/ml
83 Ringer Laktat
84 Salbutamol 2 mg (Grafalin 2 mg)
85 Salbutamol 4 mg
Salep 2-4, kombinasi: asam salisilat 2% + belerang
86 endap 4%
87 Sefadroksil sirup kering 125 mg/5 ml
88 Sefadroksil tablet/kapsul/kaplet 500 mg
89 Setirizin sirup 5 mg/5 ml
90 Setirizin tablet/kapsul/kaplet 10 mg
91 Siprofloxasin 500 mg
92 Trikresol Formalin 10 ml
93 L-Bio Sachet
94 Vitamin B Kompleks tablet (novabcomp)
95 Zinc Tablet 20 mg
96 Salon pas jet spray
97 Furosemida 40 mg
98 Alprazolam 0,5 mg
99 Parasetamol infus
100 Ketopropen supp
101 Sucralfat susp 500mg/5ml
102 Asam tranexsamat injeksi 50mg/ml
103 Domperidon tablet 10 mg
104 Ondansetron inj 2mg/ml
105 Ketokonazole 200 mg
106 Domperidon syr 5mg/5ml
107 Amoksisilin sirup 250 mg
108
109
B. PERBEKALAN KESEHATAN
1 Infus Set Anak
2 IV Catheter 18G X 1-1/4"
3 IV Catheter 20G X 1-1/4"
 4 IV Catheter 22G X 1"
5 IV Catheter 24G X 3/4"
6 AXIMED FACK MASK TIES ON
7 Sarung Tangan Non Steril Ukuran L
8 Sarung Tangan Non Steril Ukuran M
9 Infus Set Dewasa
10 Sarung Tangan Steril Ukuran 6,5
11 Sarung Tangan Steril Ukuran 7,0
12 Sarung Tangan Steril Ukuran 7,5
13 NASAL OXYGEN, O2 cannula, size XS (Bayi)
14 NASAL OXYGEN, O2 cannula, size S (Anak)
15 NASAL OXYGEN, O2 cannula, size M (Dewasa)
16 Kasa Hidrofile 40 yard x 80 cm
17 Kasa Hidrofile 3 yard x 15 cm (PACK/50 pc)
Spuit 1 cc (NIPRO Syringe 1cc Tuberculin with
18 Needle 26GX1/2" E Beam Sterilization)

Spuit 3 cc (NIPRO Syringe 3cc Luer Lock With

19 Needle 23GX1-1/4" Elektron Beam Sterilization)

Spuit 5 cc (NIPRO Syringe 5cc Luer Lock With

20 Needle 22GX1-1/2" Elektron Beam Sterilization)

Spuit 10 cc (NIPRO Syringe 10cc Luer Lock With

21 Needle 21GX1-1/2" Elektron Beam Sterilization)

22 Silk 3/0 + Jarum 1/2 GT 35 mm

23 Kapas Pembalut 250g
24 Masker N95
25 Urine Bag Sterile
26 My Jelly 82 gram
27 My Jelly 5 gram steril
28 Sabun Aseptic Gel 500 cc + dispenser
29 Sabun Anti Bakteri 500 ml + disp
30 Onemed Asept 500 ml
31 Odex 500 ml
32 Aseptan 500 cc + pump
33 Onescrub 2% 100 ml
34 Onescrub 500 cc + dispenser
35 Onescrub 5 liter
36 Softpad (Underpad) 60 x 90 cm Non Steril
37 USG Gel 250 ml
38 USG Gel 5 L
39 Sarung Tangan Obgyn Steril ( Obgyn glove)
40 Alkohol 70% 1000 ml
41 Twist Blood Lancet
42 Alcohol Swab
43 Benang Operasi Plain Catgut With Needle 3.0
44 Benang Operasi Cromic Catgut With Needle 3.0
45 Foley Catether 2 Way Fr. 18 (Box/10pcs)
46 Foley Catether 2 Way Fr. 20 (Box/10pcs)
47 Plester Rol Kain 5 cm x 4.5 m
48 Gelang Pasien (Merah muda)
49 Gelang Pasien (Biru)
50 Gelang Pasien (Kuning)
51 Masker Nebulizer Anak
52 Masker Nebulizer Dewasa
53 Chlorin 1000 ml
54 Jarum Suntik 23 G
55 Kertas Puyer 500 Lembar
56 Klip Obat Sablon Besar
57 Klip Obat Sablon Kecil
58 Klip Obat Sablon Sedang
59 Steril Scapel Blades No.11
60 Pembersih Lantai 800 ml Refill
61 Perhidrol ( H2O2 ) 3% 1000 ml
62 Spalk First Aid
63 Tissu 250 sheet
64 Spiritus 1000 ml
65 Pengharum Ruangan 250 ml
66 Klem Tali Pusar

1 JAYAMAS Onemed Catgut Plain 3/0 + Jarum 1/2

GT35 mm
2 JAYAMAS Onemed Catgut Chromic 3/0 + jarum
1/2 GT 35 mm
3 JAYAMAS Onemed My Jelly 5 gram steril
4
JAYAMAS Onemed Aseptic Gel 500 cc + dispenser
5
JAYAMAS Onemed OneScrub 500 cc + dispenser
6 JAYAMAS Onemed OneScrub 5 liter
7 JAYAMAS Onemed USG Gel 250ml
8 JAYAMAS Onemed USG Gel 5L
9 JAYAMAS Onemed Lysol 1 Liter
10 JAYAMAS Onemed Surgical Mask Plus 3 Ply Plus
Earloop
11 Aximed EXAMINATION GLOVES, size S
12 Aximed STOMACH TUBE, 85cm, no. 18
13 Aximed FEEDING TUBE, 100cm, no. 8
14 Aximed FEEDING TUBE, 40cm, no. 8
15 Kertas Puyer 500 Lembar
16 Klip Obat Sablon Besar
17 Klip Obat Sablon Sedang
18 Steril Scapel Blades No.11
19 Pembersih Lantai 800 ml Refill
20 Perhidrol ( H2O2 ) 3% 1000 ml
21 Spalk First Aid
22 Pengharum Ruangan 250 ml refill matic
23 Bahan Pengharum ruangan
24 Tisue gulung
25 Kertas USG
26 kantong puyer
27 Kartu gol darah
28 Maternity Softex
29 Tabung EDTA
30 Jarum Vacutainer
31
32
18 19 20 21 22 23 24 25 26
27 28 29 30 31
TOTAL

0
100
0
200
0
0
0
0
300
200
0
0
200
0
0
0
0
0
0
0
200
0
200
0
0
0
0
0
0
0
0
0
0
0
0
20
200
30
0
0
0
0
 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
200
0
0
0
0
0
0
0
0
0
0
0
0
0
200
0
0
0
0
0
0
0
0
0
200
0
200
0
0
0
0
0
30
0
0
0
0
0
0
0
0
0
0
0
0
0
200
0
0
0
0
0
0
0
0
0
0
0
0
0
0
200
0
0
0
200
0
0
0
0
0
0
200
100
0
0
0
0
0
200
0
0
60
0
0
0
0
60
0
0
0
0
0
0
200
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
180
0
100
0
0
0
0
0
200
0
0
0
0
0
0
0
30
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
45
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 1 2 3 4
NAMA UNIT :
BULAN :
A. OBAT- OBATAN
1 Albendazole 400 mg
2 Alopurinol 100 mg
3 Alprazolam 1 mg
4 Ambroxol 30 mg
5 Ambroxol Sirup 15 mg/ 5ml
6 Aminophilin 200 mg
7 Aminophillin Injeksi 24 mg/ml
8 Amitriptilina Tab 25 mg
9 Amlodipin 5 mg
10 Amoksisilin 500 mg
11 Amoksisilin Sirup Kering 125 mg/5ml
12 Ampisilin Injeksi 1 gram
13 Antasida Doen I Tablet Kunyah
14 Antasida Doen II Suspensi
15 Anti Bakteri Doen Salep Kombinasi
16 Anti Haemoroid DOEN Kombinasi (Superhoid)
17 Aqua Pro Injeksi Steril bebas pirogen
18 Artemeter Injeksi
19 Artesunate Injeksi
20 Asam Asetilsalisilat (Asetosal) 100 mg
21 Asam Askorbat 50 mg
22 Asam Folat 0,4 mcg
23 Asam Mefenamat 500 mg
24 Asiklovir 400 mg
25 Asiklovir Krim (Lacyvir)
26 Atapulgit 600 mg (New Antides)
27 Atropin Sulfat Injeksi 0,2 mg/ml
28 Azitromisin 500 mg
29 Bedak Salisil Serbuk 2%
30 Betametason Krim 0,1%
31 Bisakodil 10 mg Suppositoria
32 Bisakodil 5 mg Suppositoria
33 Camabion
34 Caviplex
35 Cefotaxim Injeksi
36 Combivent UDV
37 Deksametason 0,5 mg
38 Deksametason Injeksi 5 mg/ml
39 Devitalisasi Pasta Non Arsen
40 Diazepam Enema 5 mg/2,5 ml (Stesolid)
41 Diazepam Inj 5 mg/ml 2ml
42 Diazepam tablet 2 mg
43 Difenhidramine Injeksi 10 mg/ml Hcl
44 Digoksin 0,25 mg
45 Doksisiklin 100 mg
46 Epinefrin (Adrenalin) Injeksi1 mg/ml (0,1%)
47 Etabion
48 Etakridin (Rivanol) Lar 0,1 %
49 Etil Klorida Semprot
50 Eugenol Cairan
51 Famotidin 40 mg (Pratifar)
52 Fenobarbital 30 mg
53 Fenobarbital Injeksi 50 mg/ml
54 Fenol Gliserol TT 10 %
55 Fitomenadion (Vit. K1) 10 mg
56 Fitomenadion Inj 10 mg/ml
57 Furosemid 40 mg
58 Furosemid Injeksi
59 Garam Oralit 200 ml
60 Gentamicin
61 Gentian Violet Lar 1 %
62 Glass Ionomer Cemen (GCIX)
63 Glibenclamid Tab 5 mg (Trodeb))
64 Glukosa Infus 10 %
65 Glukosa Infus 40 %
66 Glukosa Larutan Infus 5%
67 Guaifenesin Tab 100 mg
68 Haloperidol 5 mg
69 Hidrokortison Krim 2,5%
70 Ibuprofen 400 mg
71 Ibuprofen Suspensi 100 mg/5ml
72 Isosorbid Dinitrat 5 mg
73 Kalsium Gluconat Injeksi 100 mg
74 Kalsium Hidroksida Pasta
75 Kalsium Laktat
76 Kaptopril 12,5 mg
77 Kaptopril 25 mg
78 Karbamazepin 200 mg
79 Ketokonazole 200 mg
80 Ketoprofen Injeksi
81 Kloramfenikol 250 mg
82 Kloramfenikol 500 mg (Chloramex)
83 Kloramfenikol SM 1 %
84 Kloramfenikol Suspensi 125 mg/5 ml
85 Kloramfenikol TM 0,5%
86 Klorampenikol TT 3 %
87 Klorfeniramina Maleat (CTM) 4 mg
88 Klorpromazina100 mg
89 Kotrimoksazole 480 mg
90 Kotrimoksazole Suspensi
91 Kuinin Dihidroksida Injeksi 25 %
92 Kuinin Sulfat 222 mg
93 Larutan KDN1 500 ML
94 Lidokain Hcl Injeksi 2%
95 Lidokain Kompositum Injeksi
96 Lodomer Injeksi
97 Magnesium Sulfat Inj(IV) 40 %
98 Metformin 500 mg
100 Metilergometrin Maleat Injeksi 0,2 mg /ml
101 Metilergometrin Maleat tab 0,125 mg
103 Metoklopramid 5 mg
104 Metoklopramid Injeksi 5 mg/ml
105 Metoklopramide Sirup 5 mg/5 ml
106 Metoklopramide10 mg
107 Metronidazol 500 mg
108 Mikonazol Krim 2%
109 Mumifaying Pasta
110 Chlor Phenol Kamfer Menthol
111 Natrium Diklofenak 50 mg
112 Natrium Klorida 0.9%
113 Neodin10% 300 ml (Afifarma)
114 Nifedipin 10 mg
115 Nistatin 500.000 IU/G
116 Oat FDC Anak
117 OAT FDC I
118 Oat FDC II
119 Obat Anti Malaria ( Arterakin )
120 OBH Cairan
121 Oksitetrasikli SM 1 %
122 Oksitetrasiklin HCl Inj 50 mg/ml 10 ml
123 Oksitetrasilin SK 3 %
124 Oksitosin Injeksi
125 Paracetamol drop 60 mg/0.6 ml (Fasidol)
126 Parasetamol 500 mg
127 Parasetamol Rectal
128 Parasetamol Sirup 120 mg/5 ml
129 Pehacain Injeksi
130 Piridoksin (Vit. B6) 10 mg (Hcl)
131 Piroxicam10 mg
132 Prednison 5 mg
133 Primakuin15 mg
134 Prokain Benzil Penisilin Inj 3 Juta IU/vial
135 Propanolol 40 mg
136 Propil Tio Urasil100 mg
137 Ranitidin 150 mg
138 Ranitidin Injeksi 25 mg/ml
139 Retinol (Vit. A) Kapsul Lunak 100.000 IU
140 Retinol (Vit. A) Kapsul Lunak 200.000 IU
141 Ringer Laktat
142 Risperidon
143 Sabu Polivalen 5 ml (ABU I)
144 Salbutamol 2 mg
145 Salbutamol 4 mg
146 Salep 24
147 Sefiksim 100 mg
148 Semen Seng Posfat
149 Serum ATS 1500 IU / Ampul
150 Sianokobalamin Injeksi (Vit. B12) 500 MCG
151 Silver Amalgam
152 Simvastatin 10 mg
153 Siprofloksasin 500 mg
154 Skizonoat Injeksi
155 Tablet Tambah Darah Fero Fumarat 60 mg + Asam
Folat 0,4 mg
156 Temporary Stopping Fletcher Serbuk

157 Thiamin Hcl (Vit B1) Inj 100 mg/ml

158 Tiamin (Vit. B1) 50 mg
159 Triheksipenidil 2 mg
160 Trikresolformalin (TKF) Cairan
161 Ventolin Nebulizer
162 Vitamin B Kompleks
163 Zinc 20 mg
164 Zink Sirup 10 mg/ml

B. VAKSIN
1 HBU
2 DPT HB HIB
3 BCG
4 POLIO ( OPV )
5 IPV
6 CAMPAK
7 TD

C. PERBEKALAN KESEHATAN
1 Alkohol 70% 1000 ml (Afifarma)
2 Catgut Chromic 3/0 with needle
3 Catgut Plain 3/0 with needle
6 Infus Set Anak
7 Infus Set Dewasa
 8 IV Catheter 18G X 1-1/4"
9 IV Catheter 20G X 1-1/4"
10 IV Catheter 22G X 1"
11 IV Catheter 24G X 3/4"
12 Jarum Suntik
13 Kapas Pembalut 250 gram
14 Kasa Hidrofile 3 yard X 15 cm
15 Kasa Hidrofile 40 yard X 80 cm
16 Kasa Pembalut 4 Yard x 15 cm
17 Masker
23 Plester Rol Kain 5 cm X 4,5 m
24 Plester Transparant
25 Sarung Tangan Non Steril
26 Sarung Tangan Obgin Steril No. 6,5
27 Sarung Tangan Obgin Steril No. 7,0
28 Sarung Tangan Steril No. 6,5
29 Sarung Tangan Steril No. 7,0
30 Sarung Tangan Steril No. 7,5
31 Silk 3/0 with needle
34 Spuit 1 cc tb
35 Spuit 3 cc
36 Spuit 5 cc
37 Spuit 10 cc
D. TAMBAHAN
T-1 Foley Catheter 20
T-2 Softpad (Under Pad)
T-3 umblical clem
T-4 Urine Bag Sterile
T-5 Nasal Oksigen Bayi
T-6 Nasal Oksigen Anak
T-7 Nasal Oksigen Dewasa
T-8 PP INH
T-9 Glimepirid
T-10 Acetylcystein 200 mg
T-11 Sefadroxil syrup
T-12 Ketorolac Inj
T-13 Plesterin bulat soft
T-14 WIDABES
T-15 Spalk
T-16 Xylocain spray 10%
T-17 Kombipak azithromycin cefixime
T-18 Cetirizin 10 mg
T-19 Methylprednisolon 4 mg
T-20 Ondansetron inj
T-21 Ibuprofen 200mg
T-22 Kombipa FDC I
 T-23 Bayclin lar pemutih
T-24 Omeprazole 20 mg
T-25 Foley Catheter 18
T-26 Cefotaxime inj 1gr
T-27 Ketoprofen supp
T-28 Aminophilin 150 mg
T-29 Parasetamol infus
T-30 sarung tangan non steril S
T-31 sarung tangan non steril M
T-32 sarung tangan non steril L
T-33 tranexamat acid inj 5%
T-34 Amoxicilin drop
T-35 ceterizin syr
T-36 Klozapin tab
T-37 Sucralfat syr
II. JAMINAN KESEHATAN NASIONAL
1 Aminofilin inj 24 mg/ml
2 Amlodipin tablet/kapsul/kaplet 5 mg
3 Amoksisilin kapsul/kaplet/tablet scored 500 mg
4 amoxisilin 500 (novamox)
5 Amoksisilin sirup kering 125 mg/5 ml
6 Anti Bakteri DOEN Salep Kombinasi
7 Aqua pro injeksi
8 Asam asetilsalisilat (asetosal) 100 mg
9 Asam Mefenamat
10 Asiklovir 400 mg
11 Asiklovir Cream
12 Attapulgit
13 Bedak salisil serbuk 2%
14 Betahistin tablet/kapsul/kaplet 6 mg
15 Bisakodil tablet/kapsul/kaplet 5 mg
16 (Chlor Phenol Kamper Menthol (CHKM) 10 ml
Champenol)

17 Cavit 28 gr (Bahan untuk tumpatan sementara)

18 Devitalisasi Pasta Non Arsen
19 Deksametason Injeksi
20 Deksametason 0,5 mg (faridexon)
21 Dextrose 40%
22 Diazepam tab (stesolid)
23 Diazepam inj (stesolid)
24 Dipenhidramin
25 Domperidon 10 mg
26 Domperidon Sirup
27 Etil Klorida Semprot 100 ml Spray
28 Fitomenadion (Vit K1) 10 mg
29 Fitomenadion inj.
GENERIK Amoksisilin sirup kering forte 250 mg/ 5
30 ml

31 GENERIK Glimepiride tablet/kapsul/kaplet 2 mg

32 Gentamicin inj
Glass Ionomer Cemen ( Powder 15gr,Liquid 8gr
33 (6.4ml))
34 Griseofulfin Tab 125 mg
35 Hyoscine-N-butylbromide 10 mg
36 Hyoscine-N-butylbromide 20 mg/ml Injeksi
37 Hidrocortison sk
38 Kalsium Glukonat inj i.v 10%
39 Kalsium Hidroksida Pasta (Hydcal)
40 Kalsium Laktat (LIKOKALK)
41 Kaptopril tablet/ 50 mg
42 ketokonazole SK
43 Ketorolak inji 30 mg/ml
44 Klindamisin tablet/kapsul/kaplet 300 mg
45 Klorfeniramina Maleat 4 mg (CTM)
46 Klorfeniramina Maleat 4 mg (CTM) 2016
47 Kloramfenikol tetes mata 0,5%
48 kloramfenikol SM
49 kloramfenikol kapsul 250mg (microtina)
50 Klorpromazin 100 mg
51 kotrimoxazole D
52 Lidokain inj.
53 Loperamid tablet/kapsul/kaplet 2 mg
54 Metformin HCl tablet/kapsul/kaplet 500 mg
55 Metilergometrin maleat Tab 0,125 mg
56 Metilprednisolon tablet/kapsul/kaplet 4 mg
57 Metoklopramide sirup 5 mg/ 5 ml
58 Metoklopramide tablet/kapsul/kaplet 10 mg
59 MGSO4 40 Magnesium sulfat Injeksi 40%
60 Multivitamin (Betafort Sirup)
61 Multivitamin (Caviplex syrup)
62 Multivitamin (Livron B plex)
63 Mumifaying pasta ( Cresotin Paste)
64 Natrium diklofenak tablet/kapsul/kaplet 50 mg
65 Natrium klorida Infus 0,9%
66 NEODIN 10 % 300 ml
NEUROBION (Vit.B1 100 mg, vit B6 100 mg, vit
67 B12 5.000 mcg) 3ml Injeksi
68 Oksimetazolin tetes hidung 0,025%
69 Oksimetazolin tetes hidung 0,050%
70 Omeprazol tablet/kapsul/kaplet 20 mg
71 Ondansetron inj 2 mg/ml (4 mg/ 2 mL)
72 Oxitocin inj.
73 Papaverin Tablet
74 Parasetamol drips (infus) 1000 mg/100ml
75 Parasetamol sirup 120 mg / 5 ml
76 Parasetamol Tab 500 mg
77 Piracetam 800 mg
78 Piridoksin HCL Tab 10mg ( vitamin B6)
79 Piroxicam (ROSIC)
80 Prednison Tab 5 mg
81 Ranitidin 150 mg
82 Ranitidin Injeksi 25 mg/ml
83 Ringer Laktat
84 Salbutamol 2 mg (Grafalin 2 mg)
85 Salbutamol 4 mg
Salep 2-4, kombinasi: asam salisilat 2% + belerang
86 endap 4%
87 Sefadroksil sirup kering 125 mg/5 ml
88 Sefadroksil tablet/kapsul/kaplet 500 mg
89 Setirizin sirup 5 mg/5 ml
90 Setirizin tablet/kapsul/kaplet 10 mg
91 Siprofloxasin 500 mg
92 Trikresol Formalin 10 ml
93 L-Bio Sachet
94 Vitamin B Kompleks tablet (novabcomp)
95 Zinc Tablet 20 mg
96 Salon pas jet spray
97 Furosemida 40 mg
98 Alprazolam 0,5 mg
99 Parasetamol infus
100 Ketopropen supp
101 Sucralfat susp 500mg/5ml
102 Asam tranexsamat injeksi 50mg/ml
103 Domperidon tablet 10 mg
104 Ondansetron inj 2mg/ml
105 Ketokonazole 200 mg
106 Domperidon syr 5mg/5ml
107 Amoksisilin sirup 250 mg
108
109
B. PERBEKALAN KESEHATAN
1 Infus Set Anak
2 IV Catheter 18G X 1-1/4"
3 IV Catheter 20G X 1-1/4"
 4 IV Catheter 22G X 1"
5 IV Catheter 24G X 3/4"
6 AXIMED FACK MASK TIES ON
7 Sarung Tangan Non Steril Ukuran L
8 Sarung Tangan Non Steril Ukuran M
9 Infus Set Dewasa
10 Sarung Tangan Steril Ukuran 6,5
11 Sarung Tangan Steril Ukuran 7,0
12 Sarung Tangan Steril Ukuran 7,5
13 NASAL OXYGEN, O2 cannula, size XS (Bayi)
14 NASAL OXYGEN, O2 cannula, size S (Anak)
15 NASAL OXYGEN, O2 cannula, size M (Dewasa)
16 Kasa Hidrofile 40 yard x 80 cm
17 Kasa Hidrofile 3 yard x 15 cm (PACK/50 pc)
Spuit 1 cc (NIPRO Syringe 1cc Tuberculin with
18 Needle 26GX1/2" E Beam Sterilization)

Spuit 3 cc (NIPRO Syringe 3cc Luer Lock With

19 Needle 23GX1-1/4" Elektron Beam Sterilization)

Spuit 5 cc (NIPRO Syringe 5cc Luer Lock With

20 Needle 22GX1-1/2" Elektron Beam Sterilization)

Spuit 10 cc (NIPRO Syringe 10cc Luer Lock With

21 Needle 21GX1-1/2" Elektron Beam Sterilization)

22 Silk 3/0 + Jarum 1/2 GT 35 mm

23 Kapas Pembalut 250g
24 Masker N95
25 Urine Bag Sterile
26 My Jelly 82 gram
27 My Jelly 5 gram steril
28 Sabun Aseptic Gel 500 cc + dispenser
29 Sabun Anti Bakteri 500 ml + disp
30 Onemed Asept 500 ml
31 Odex 500 ml
32 Aseptan 500 cc + pump
33 Onescrub 2% 100 ml
34 Onescrub 500 cc + dispenser
35 Onescrub 5 liter
36 Softpad (Underpad) 60 x 90 cm Non Steril
37 USG Gel 250 ml
38 USG Gel 5 L
39 Sarung Tangan Obgyn Steril ( Obgyn glove)
40 Alkohol 70% 1000 ml
41 Twist Blood Lancet
42 Alcohol Swab
43 Benang Operasi Plain Catgut With Needle 3.0
44 Benang Operasi Cromic Catgut With Needle 3.0
45 Foley Catether 2 Way Fr. 18 (Box/10pcs)
46 Foley Catether 2 Way Fr. 20 (Box/10pcs)
47 Plester Rol Kain 5 cm x 4.5 m
48 Gelang Pasien (Merah muda)
49 Gelang Pasien (Biru)
50 Gelang Pasien (Kuning)
51 Masker Nebulizer Anak
52 Masker Nebulizer Dewasa
53 Chlorin 1000 ml
54 Jarum Suntik 23 G
55 Kertas Puyer 500 Lembar
56 Klip Obat Sablon Besar
57 Klip Obat Sablon Kecil
58 Klip Obat Sablon Sedang
59 Steril Scapel Blades No.11
60 Pembersih Lantai 800 ml Refill
61 Perhidrol ( H2O2 ) 3% 1000 ml
62 Spalk First Aid
63 Tissu 250 sheet
64 Spiritus 1000 ml
65 Pengharum Ruangan 250 ml
66 Klem Tali Pusar

1 JAYAMAS Onemed Catgut Plain 3/0 + Jarum 1/2

GT35 mm
2 JAYAMAS Onemed Catgut Chromic 3/0 + jarum
1/2 GT 35 mm
3 JAYAMAS Onemed My Jelly 5 gram steril
4
JAYAMAS Onemed Aseptic Gel 500 cc + dispenser
5
JAYAMAS Onemed OneScrub 500 cc + dispenser
6 JAYAMAS Onemed OneScrub 5 liter
7 JAYAMAS Onemed USG Gel 250ml
8 JAYAMAS Onemed USG Gel 5L
9 JAYAMAS Onemed Lysol 1 Liter
10 JAYAMAS Onemed Surgical Mask Plus 3 Ply Plus
Earloop
11 Aximed EXAMINATION GLOVES, size S
12 Aximed STOMACH TUBE, 85cm, no. 18
13 Aximed FEEDING TUBE, 100cm, no. 8
14 Aximed FEEDING TUBE, 40cm, no. 8
15 Kertas Puyer 500 Lembar
16 Klip Obat Sablon Besar
17 Klip Obat Sablon Sedang
18 Steril Scapel Blades No.11
19 Pembersih Lantai 800 ml Refill
20 Perhidrol ( H2O2 ) 3% 1000 ml
21 Spalk First Aid
22 Pengharum Ruangan 250 ml refill matic
23 Bahan Pengharum ruangan
24 Tisue gulung
25 Kertas USG
26 kantong puyer
27 Kartu gol darah
28 Maternity Softex
29 Tabung EDTA
30 Jarum Vacutainer
31
32
5 6 7 8 9 10 11 12 13
14 15 16 17 18 19 20 21 22
23 24 25 26 27 28 29 30 31
TOTAL

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 1 2 3 4
NAMA UNIT :
BULAN :
A. OBAT- OBATAN
1 Albendazole 400 mg
2 Alopurinol 100 mg
3 Alprazolam 1 mg
4 Ambroxol 30 mg
5 Ambroxol Sirup 15 mg/ 5ml
6 Aminophilin 200 mg
7 Aminophillin Injeksi 24 mg/ml
8 Amitriptilina Tab 25 mg
9 Amlodipin 5 mg
10 Amoksisilin 500 mg
11 Amoksisilin Sirup Kering 125 mg/5ml
12 Ampisilin Injeksi 1 gram
13 Antasida Doen I Tablet Kunyah
14 Antasida Doen II Suspensi
15 Anti Bakteri Doen Salep Kombinasi
16 Anti Haemoroid DOEN Kombinasi (Superhoid)
17 Aqua Pro Injeksi Steril bebas pirogen
18 Artemeter Injeksi
19 Artesunate Injeksi
20 Asam Asetilsalisilat (Asetosal) 100 mg
21 Asam Askorbat 50 mg
22 Asam Folat 0,4 mcg
23 Asam Mefenamat 500 mg
24 Asiklovir 400 mg
25 Asiklovir Krim (Lacyvir)
26 Atapulgit 600 mg (New Antides)
27 Atropin Sulfat Injeksi 0,2 mg/ml
28 Azitromisin 500 mg
29 Bedak Salisil Serbuk 2%
30 Betametason Krim 0,1%
31 Bisakodil 10 mg Suppositoria
32 Bisakodil 5 mg Suppositoria
33 Camabion
34 Caviplex
35 Cefotaxim Injeksi
36 Combivent UDV
37 Deksametason 0,5 mg
38 Deksametason Injeksi 5 mg/ml
39 Devitalisasi Pasta Non Arsen
40 Diazepam Enema 5 mg/2,5 ml (Stesolid)
41 Diazepam Inj 5 mg/ml 2ml
42 Diazepam tablet 2 mg
43 Difenhidramine Injeksi 10 mg/ml Hcl
44 Digoksin 0,25 mg
45 Doksisiklin 100 mg
46 Epinefrin (Adrenalin) Injeksi1 mg/ml (0,1%)
47 Etabion
48 Etakridin (Rivanol) Lar 0,1 %
49 Etil Klorida Semprot
50 Eugenol Cairan
51 Famotidin 40 mg (Pratifar)
52 Fenobarbital 30 mg
53 Fenobarbital Injeksi 50 mg/ml
54 Fenol Gliserol TT 10 %
55 Fitomenadion (Vit. K1) 10 mg
56 Fitomenadion Inj 10 mg/ml
57 Furosemid 40 mg
58 Furosemid Injeksi
59 Garam Oralit 200 ml
60 Gentamicin
61 Gentian Violet Lar 1 %
62 Glass Ionomer Cemen (GCIX)
63 Glibenclamid Tab 5 mg (Trodeb))
64 Glukosa Infus 10 %
65 Glukosa Infus 40 %
66 Glukosa Larutan Infus 5%
67 Guaifenesin Tab 100 mg
68 Haloperidol 5 mg
69 Hidrokortison Krim 2,5%
70 Ibuprofen 400 mg
71 Ibuprofen Suspensi 100 mg/5ml
72 Isosorbid Dinitrat 5 mg
73 Kalsium Gluconat Injeksi 100 mg
74 Kalsium Hidroksida Pasta
75 Kalsium Laktat
76 Kaptopril 12,5 mg
77 Kaptopril 25 mg
78 Karbamazepin 200 mg
79 Ketokonazole 200 mg
80 Ketoprofen Injeksi
81 Kloramfenikol 250 mg
82 Kloramfenikol 500 mg (Chloramex)
83 Kloramfenikol SM 1 %
84 Kloramfenikol Suspensi 125 mg/5 ml
85 Kloramfenikol TM 0,5%
86 Klorampenikol TT 3 %
87 Klorfeniramina Maleat (CTM) 4 mg
88 Klorpromazina100 mg
89 Kotrimoksazole 480 mg
90 Kotrimoksazole Suspensi
91 Kuinin Dihidroksida Injeksi 25 %
92 Kuinin Sulfat 222 mg
93 Larutan KDN1 500 ML
94 Lidokain Hcl Injeksi 2%
95 Lidokain Kompositum Injeksi
96 Lodomer Injeksi
97 Magnesium Sulfat Inj(IV) 40 %
98 Metformin 500 mg
100 Metilergometrin Maleat Injeksi 0,2 mg /ml
101 Metilergometrin Maleat tab 0,125 mg
103 Metoklopramid 5 mg
104 Metoklopramid Injeksi 5 mg/ml
105 Metoklopramide Sirup 5 mg/5 ml
106 Metoklopramide10 mg
107 Metronidazol 500 mg
108 Mikonazol Krim 2%
109 Mumifaying Pasta
110 Chlor Phenol Kamfer Menthol
111 Natrium Diklofenak 50 mg
112 Natrium Klorida 0.9%
113 Neodin10% 300 ml (Afifarma)
114 Nifedipin 10 mg
115 Nistatin 500.000 IU/G
116 Oat FDC Anak
117 OAT FDC I
118 Oat FDC II
119 Obat Anti Malaria ( Arterakin )
120 OBH Cairan
121 Oksitetrasikli SM 1 %
122 Oksitetrasiklin HCl Inj 50 mg/ml 10 ml
123 Oksitetrasilin SK 3 %
124 Oksitosin Injeksi
125 Paracetamol drop 60 mg/0.6 ml (Fasidol)
126 Parasetamol 500 mg
127 Parasetamol Rectal
128 Parasetamol Sirup 120 mg/5 ml
129 Pehacain Injeksi
130 Piridoksin (Vit. B6) 10 mg (Hcl)
131 Piroxicam10 mg
132 Prednison 5 mg
133 Primakuin15 mg
134 Prokain Benzil Penisilin Inj 3 Juta IU/vial
135 Propanolol 40 mg
136 Propil Tio Urasil100 mg
137 Ranitidin 150 mg
138 Ranitidin Injeksi 25 mg/ml
139 Retinol (Vit. A) Kapsul Lunak 100.000 IU
140 Retinol (Vit. A) Kapsul Lunak 200.000 IU
141 Ringer Laktat
142 Risperidon
143 Sabu Polivalen 5 ml (ABU I)
144 Salbutamol 2 mg
145 Salbutamol 4 mg
146 Salep 24
147 Sefiksim 100 mg
148 Semen Seng Posfat
149 Serum ATS 1500 IU / Ampul
150 Sianokobalamin Injeksi (Vit. B12) 500 MCG
151 Silver Amalgam
152 Simvastatin 10 mg
153 Siprofloksasin 500 mg
154 Skizonoat Injeksi
155 Tablet Tambah Darah Fero Fumarat 60 mg + Asam
Folat 0,4 mg
156 Temporary Stopping Fletcher Serbuk

157 Thiamin Hcl (Vit B1) Inj 100 mg/ml

158 Tiamin (Vit. B1) 50 mg
159 Triheksipenidil 2 mg
160 Trikresolformalin (TKF) Cairan
161 Ventolin Nebulizer
162 Vitamin B Kompleks
163 Zinc 20 mg
164 Zink Sirup 10 mg/ml

B. VAKSIN
1 HBU
2 DPT HB HIB
3 BCG
4 POLIO ( OPV )
5 IPV
6 CAMPAK
7 TD

C. PERBEKALAN KESEHATAN
1 Alkohol 70% 1000 ml (Afifarma)
2 Catgut Chromic 3/0 with needle
3 Catgut Plain 3/0 with needle
6 Infus Set Anak
7 Infus Set Dewasa
 8 IV Catheter 18G X 1-1/4"
9 IV Catheter 20G X 1-1/4"
10 IV Catheter 22G X 1"
11 IV Catheter 24G X 3/4"
12 Jarum Suntik
13 Kapas Pembalut 250 gram
14 Kasa Hidrofile 3 yard X 15 cm
15 Kasa Hidrofile 40 yard X 80 cm
16 Kasa Pembalut 4 Yard x 15 cm
17 Masker
23 Plester Rol Kain 5 cm X 4,5 m
24 Plester Transparant
25 Sarung Tangan Non Steril
26 Sarung Tangan Obgin Steril No. 6,5
27 Sarung Tangan Obgin Steril No. 7,0
28 Sarung Tangan Steril No. 6,5
29 Sarung Tangan Steril No. 7,0
30 Sarung Tangan Steril No. 7,5
31 Silk 3/0 with needle
34 Spuit 1 cc tb
35 Spuit 3 cc
36 Spuit 5 cc
37 Spuit 10 cc
D. TAMBAHAN
T-1 Foley Catheter 20
T-2 Softpad (Under Pad)
T-3 umblical clem
T-4 Urine Bag Sterile
T-5 Nasal Oksigen Bayi
T-6 Nasal Oksigen Anak
T-7 Nasal Oksigen Dewasa
T-8 PP INH
T-9 Glimepirid
T-10 Acetylcystein 200 mg
T-11 Sefadroxil syrup
T-12 Ketorolac Inj
T-13 Plesterin bulat soft
T-14 WIDABES
T-15 Spalk
T-16 Xylocain spray 10%
T-17 Kombipak azithromycin cefixime
T-18 Cetirizin 10 mg
T-19 Methylprednisolon 4 mg
T-20 Ondansetron inj
T-21 Ibuprofen 200mg
T-22 Kombipa FDC I
 T-23 Bayclin lar pemutih
T-24 Omeprazole 20 mg
T-25 Foley Catheter 18
T-26 Cefotaxime inj 1gr
T-27 Ketoprofen supp
T-28 Aminophilin 150 mg
T-29 Parasetamol infus
T-30 sarung tangan non steril S
T-31 sarung tangan non steril M
T-32 sarung tangan non steril L
T-33 tranexamat acid inj 5%
T-34 Amoxicilin drop
T-35 ceterizin syr
T-36 Klozapin tab
T-37 Sucralfat syr
II. JAMINAN KESEHATAN NASIONAL
1 Aminofilin inj 24 mg/ml
2 Amlodipin tablet/kapsul/kaplet 5 mg
3 Amoksisilin kapsul/kaplet/tablet scored 500 mg
4 amoxisilin 500 (novamox)
5 Amoksisilin sirup kering 125 mg/5 ml
6 Anti Bakteri DOEN Salep Kombinasi
7 Aqua pro injeksi
8 Asam asetilsalisilat (asetosal) 100 mg
9 Asam Mefenamat
10 Asiklovir 400 mg
11 Asiklovir Cream
12 Attapulgit
13 Bedak salisil serbuk 2%
14 Betahistin tablet/kapsul/kaplet 6 mg
15 Bisakodil tablet/kapsul/kaplet 5 mg
16 (Chlor Phenol Kamper Menthol (CHKM) 10 ml
Champenol)

17 Cavit 28 gr (Bahan untuk tumpatan sementara)

18 Devitalisasi Pasta Non Arsen
19 Deksametason Injeksi
20 Deksametason 0,5 mg (faridexon)
21 Dextrose 40%
22 Diazepam tab (stesolid)
23 Diazepam inj (stesolid)
24 Dipenhidramin
25 Domperidon 10 mg
26 Domperidon Sirup
27 Etil Klorida Semprot 100 ml Spray
28 Fitomenadion (Vit K1) 10 mg
29 Fitomenadion inj.
GENERIK Amoksisilin sirup kering forte 250 mg/ 5
30 ml

31 GENERIK Glimepiride tablet/kapsul/kaplet 2 mg

32 Gentamicin inj
Glass Ionomer Cemen ( Powder 15gr,Liquid 8gr
33 (6.4ml))
34 Griseofulfin Tab 125 mg
35 Hyoscine-N-butylbromide 10 mg
36 Hyoscine-N-butylbromide 20 mg/ml Injeksi
37 Hidrocortison sk
38 Kalsium Glukonat inj i.v 10%
39 Kalsium Hidroksida Pasta (Hydcal)
40 Kalsium Laktat (LIKOKALK)
41 Kaptopril tablet/ 50 mg
42 ketokonazole SK
43 Ketorolak inji 30 mg/ml
44 Klindamisin tablet/kapsul/kaplet 300 mg
45 Klorfeniramina Maleat 4 mg (CTM)
46 Klorfeniramina Maleat 4 mg (CTM) 2016
47 Kloramfenikol tetes mata 0,5%
48 kloramfenikol SM
49 kloramfenikol kapsul 250mg (microtina)
50 Klorpromazin 100 mg
51 kotrimoxazole D
52 Lidokain inj.
53 Loperamid tablet/kapsul/kaplet 2 mg
54 Metformin HCl tablet/kapsul/kaplet 500 mg
55 Metilergometrin maleat Tab 0,125 mg
56 Metilprednisolon tablet/kapsul/kaplet 4 mg
57 Metoklopramide sirup 5 mg/ 5 ml
58 Metoklopramide tablet/kapsul/kaplet 10 mg
59 MGSO4 40 Magnesium sulfat Injeksi 40%
60 Multivitamin (Betafort Sirup)
61 Multivitamin (Caviplex syrup)
62 Multivitamin (Livron B plex)
63 Mumifaying pasta ( Cresotin Paste)
64 Natrium diklofenak tablet/kapsul/kaplet 50 mg
65 Natrium klorida Infus 0,9%
66 NEODIN 10 % 300 ml
NEUROBION (Vit.B1 100 mg, vit B6 100 mg, vit
67 B12 5.000 mcg) 3ml Injeksi
68 Oksimetazolin tetes hidung 0,025%
69 Oksimetazolin tetes hidung 0,050%
70 Omeprazol tablet/kapsul/kaplet 20 mg
71 Ondansetron inj 2 mg/ml (4 mg/ 2 mL)
72 Oxitocin inj.
73 Papaverin Tablet
74 Parasetamol drips (infus) 1000 mg/100ml
75 Parasetamol sirup 120 mg / 5 ml
76 Parasetamol Tab 500 mg
77 Piracetam 800 mg
78 Piridoksin HCL Tab 10mg ( vitamin B6)
79 Piroxicam (ROSIC)
80 Prednison Tab 5 mg
81 Ranitidin 150 mg
82 Ranitidin Injeksi 25 mg/ml
83 Ringer Laktat
84 Salbutamol 2 mg (Grafalin 2 mg)
85 Salbutamol 4 mg
Salep 2-4, kombinasi: asam salisilat 2% + belerang
86 endap 4%
87 Sefadroksil sirup kering 125 mg/5 ml
88 Sefadroksil tablet/kapsul/kaplet 500 mg
89 Setirizin sirup 5 mg/5 ml
90 Setirizin tablet/kapsul/kaplet 10 mg
91 Siprofloxasin 500 mg
92 Trikresol Formalin 10 ml
93 L-Bio Sachet
94 Vitamin B Kompleks tablet (novabcomp)
95 Zinc Tablet 20 mg
96 Salon pas jet spray
97 Furosemida 40 mg
98 Alprazolam 0,5 mg
99 Parasetamol infus
100 Ketopropen supp
101 Sucralfat susp 500mg/5ml
102 Asam tranexsamat injeksi 50mg/ml
103 Domperidon tablet 10 mg
104 Ondansetron inj 2mg/ml
105 Ketokonazole 200 mg
106 Domperidon syr 5mg/5ml
107 Amoksisilin sirup 250 mg
108
109
B. PERBEKALAN KESEHATAN
1 Infus Set Anak
2 IV Catheter 18G X 1-1/4"
3 IV Catheter 20G X 1-1/4"
 4 IV Catheter 22G X 1"
5 IV Catheter 24G X 3/4"
6 AXIMED FACK MASK TIES ON
7 Sarung Tangan Non Steril Ukuran L
8 Sarung Tangan Non Steril Ukuran M
9 Infus Set Dewasa
10 Sarung Tangan Steril Ukuran 6,5
11 Sarung Tangan Steril Ukuran 7,0
12 Sarung Tangan Steril Ukuran 7,5
13 NASAL OXYGEN, O2 cannula, size XS (Bayi)
14 NASAL OXYGEN, O2 cannula, size S (Anak)
15 NASAL OXYGEN, O2 cannula, size M (Dewasa)
16 Kasa Hidrofile 40 yard x 80 cm
17 Kasa Hidrofile 3 yard x 15 cm (PACK/50 pc)
Spuit 1 cc (NIPRO Syringe 1cc Tuberculin with
18 Needle 26GX1/2" E Beam Sterilization)

Spuit 3 cc (NIPRO Syringe 3cc Luer Lock With

19 Needle 23GX1-1/4" Elektron Beam Sterilization)

Spuit 5 cc (NIPRO Syringe 5cc Luer Lock With

20 Needle 22GX1-1/2" Elektron Beam Sterilization)

Spuit 10 cc (NIPRO Syringe 10cc Luer Lock With

21 Needle 21GX1-1/2" Elektron Beam Sterilization)

22 Silk 3/0 + Jarum 1/2 GT 35 mm

23 Kapas Pembalut 250g
24 Masker N95
25 Urine Bag Sterile
26 My Jelly 82 gram
27 My Jelly 5 gram steril
28 Sabun Aseptic Gel 500 cc + dispenser
29 Sabun Anti Bakteri 500 ml + disp
30 Onemed Asept 500 ml
31 Odex 500 ml
32 Aseptan 500 cc + pump
33 Onescrub 2% 100 ml
34 Onescrub 500 cc + dispenser
35 Onescrub 5 liter
36 Softpad (Underpad) 60 x 90 cm Non Steril
37 USG Gel 250 ml
38 USG Gel 5 L
39 Sarung Tangan Obgyn Steril ( Obgyn glove)
40 Alkohol 70% 1000 ml
41 Twist Blood Lancet
42 Alcohol Swab
43 Benang Operasi Plain Catgut With Needle 3.0
44 Benang Operasi Cromic Catgut With Needle 3.0
45 Foley Catether 2 Way Fr. 18 (Box/10pcs)
46 Foley Catether 2 Way Fr. 20 (Box/10pcs)
47 Plester Rol Kain 5 cm x 4.5 m
48 Gelang Pasien (Merah muda)
49 Gelang Pasien (Biru)
50 Gelang Pasien (Kuning)
51 Masker Nebulizer Anak
52 Masker Nebulizer Dewasa
53 Chlorin 1000 ml
54 Jarum Suntik 23 G
55 Kertas Puyer 500 Lembar
56 Klip Obat Sablon Besar
57 Klip Obat Sablon Kecil
58 Klip Obat Sablon Sedang
59 Steril Scapel Blades No.11
60 Pembersih Lantai 800 ml Refill
61 Perhidrol ( H2O2 ) 3% 1000 ml
62 Spalk First Aid
63 Tissu 250 sheet
64 Spiritus 1000 ml
65 Pengharum Ruangan 250 ml
66 Klem Tali Pusar

1 JAYAMAS Onemed Catgut Plain 3/0 + Jarum 1/2

GT35 mm
2 JAYAMAS Onemed Catgut Chromic 3/0 + jarum
1/2 GT 35 mm
3 JAYAMAS Onemed My Jelly 5 gram steril
4
JAYAMAS Onemed Aseptic Gel 500 cc + dispenser
5
JAYAMAS Onemed OneScrub 500 cc + dispenser
6 JAYAMAS Onemed OneScrub 5 liter
7 JAYAMAS Onemed USG Gel 250ml
8 JAYAMAS Onemed USG Gel 5L
9 JAYAMAS Onemed Lysol 1 Liter
10 JAYAMAS Onemed Surgical Mask Plus 3 Ply Plus
Earloop
11 Aximed EXAMINATION GLOVES, size S
12 Aximed STOMACH TUBE, 85cm, no. 18
13 Aximed FEEDING TUBE, 100cm, no. 8
14 Aximed FEEDING TUBE, 40cm, no. 8
15 Kertas Puyer 500 Lembar
16 Klip Obat Sablon Besar
17 Klip Obat Sablon Sedang
18 Steril Scapel Blades No.11
19 Pembersih Lantai 800 ml Refill
20 Perhidrol ( H2O2 ) 3% 1000 ml
21 Spalk First Aid
22 Pengharum Ruangan 250 ml refill matic
23 Bahan Pengharum ruangan
24 Tisue gulung
25 Kertas USG
26 kantong puyer
27 Kartu gol darah
28 Maternity Softex
29 Tabung EDTA
30 Jarum Vacutainer
31
32
5 6 7 8 9 10 11 12 13
14 15 16 17 18 19 20 21 22
23 24 25 26 27 28 29 30 31
TOTAL

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 1 2 3 4
NAMA UNIT :
BULAN :
A. OBAT- OBATAN
1 Albendazole 400 mg
2 Alopurinol 100 mg
3 Alprazolam 1 mg
4 Ambroxol 30 mg
5 Ambroxol Sirup 15 mg/ 5ml
6 Aminophilin 200 mg
7 Aminophillin Injeksi 24 mg/ml
8 Amitriptilina Tab 25 mg
9 Amlodipin 5 mg
10 Amoksisilin 500 mg
11 Amoksisilin Sirup Kering 125 mg/5ml
12 Ampisilin Injeksi 1 gram
13 Antasida Doen I Tablet Kunyah
14 Antasida Doen II Suspensi
15 Anti Bakteri Doen Salep Kombinasi
16 Anti Haemoroid DOEN Kombinasi (Superhoid)
17 Aqua Pro Injeksi Steril bebas pirogen
18 Artemeter Injeksi
19 Artesunate Injeksi
20 Asam Asetilsalisilat (Asetosal) 100 mg
21 Asam Askorbat 50 mg
22 Asam Folat 0,4 mcg
23 Asam Mefenamat 500 mg
24 Asiklovir 400 mg
25 Asiklovir Krim (Lacyvir)
26 Atapulgit 600 mg (New Antides)
27 Atropin Sulfat Injeksi 0,2 mg/ml
28 Azitromisin 500 mg
29 Bedak Salisil Serbuk 2%
30 Betametason Krim 0,1%
31 Bisakodil 10 mg Suppositoria
32 Bisakodil 5 mg Suppositoria
33 Camabion
34 Caviplex
35 Cefotaxim Injeksi
36 Combivent UDV
37 Deksametason 0,5 mg
38 Deksametason Injeksi 5 mg/ml
39 Devitalisasi Pasta Non Arsen
40 Diazepam Enema 5 mg/2,5 ml (Stesolid)
41 Diazepam Inj 5 mg/ml 2ml
42 Diazepam tablet 2 mg
43 Difenhidramine Injeksi 10 mg/ml Hcl
44 Digoksin 0,25 mg
45 Doksisiklin 100 mg
46 Epinefrin (Adrenalin) Injeksi1 mg/ml (0,1%)
47 Etabion
48 Etakridin (Rivanol) Lar 0,1 %
49 Etil Klorida Semprot
50 Eugenol Cairan
51 Famotidin 40 mg (Pratifar)
52 Fenobarbital 30 mg
53 Fenobarbital Injeksi 50 mg/ml
54 Fenol Gliserol TT 10 %
55 Fitomenadion (Vit. K1) 10 mg
56 Fitomenadion Inj 10 mg/ml
57 Furosemid 40 mg
58 Furosemid Injeksi
59 Garam Oralit 200 ml
60 Gentamicin
61 Gentian Violet Lar 1 %
62 Glass Ionomer Cemen (GCIX)
63 Glibenclamid Tab 5 mg (Trodeb))
64 Glukosa Infus 10 %
65 Glukosa Infus 40 %
66 Glukosa Larutan Infus 5%
67 Guaifenesin Tab 100 mg
68 Haloperidol 5 mg
69 Hidrokortison Krim 2,5%
70 Ibuprofen 400 mg
71 Ibuprofen Suspensi 100 mg/5ml
72 Isosorbid Dinitrat 5 mg
73 Kalsium Gluconat Injeksi 100 mg
74 Kalsium Hidroksida Pasta
75 Kalsium Laktat
76 Kaptopril 12,5 mg
77 Kaptopril 25 mg
78 Karbamazepin 200 mg
79 Ketokonazole 200 mg
80 Ketoprofen Injeksi
81 Kloramfenikol 250 mg
82 Kloramfenikol 500 mg (Chloramex)
83 Kloramfenikol SM 1 %
84 Kloramfenikol Suspensi 125 mg/5 ml
85 Kloramfenikol TM 0,5%
86 Klorampenikol TT 3 %
87 Klorfeniramina Maleat (CTM) 4 mg
88 Klorpromazina100 mg
89 Kotrimoksazole 480 mg
90 Kotrimoksazole Suspensi
91 Kuinin Dihidroksida Injeksi 25 %
92 Kuinin Sulfat 222 mg
93 Larutan KDN1 500 ML
94 Lidokain Hcl Injeksi 2%
95 Lidokain Kompositum Injeksi
96 Lodomer Injeksi
97 Magnesium Sulfat Inj(IV) 40 %
98 Metformin 500 mg
100 Metilergometrin Maleat Injeksi 0,2 mg /ml
101 Metilergometrin Maleat tab 0,125 mg
103 Metoklopramid 5 mg
104 Metoklopramid Injeksi 5 mg/ml
105 Metoklopramide Sirup 5 mg/5 ml
106 Metoklopramide10 mg
107 Metronidazol 500 mg
108 Mikonazol Krim 2%
109 Mumifaying Pasta
110 Chlor Phenol Kamfer Menthol
111 Natrium Diklofenak 50 mg
112 Natrium Klorida 0.9%
113 Neodin10% 300 ml (Afifarma)
114 Nifedipin 10 mg
115 Nistatin 500.000 IU/G
116 Oat FDC Anak
117 OAT FDC I
118 Oat FDC II
119 Obat Anti Malaria ( Arterakin )
120 OBH Cairan
121 Oksitetrasikli SM 1 %
122 Oksitetrasiklin HCl Inj 50 mg/ml 10 ml
123 Oksitetrasilin SK 3 %
124 Oksitosin Injeksi
125 Paracetamol drop 60 mg/0.6 ml (Fasidol)
126 Parasetamol 500 mg
127 Parasetamol Rectal
128 Parasetamol Sirup 120 mg/5 ml
129 Pehacain Injeksi
130 Piridoksin (Vit. B6) 10 mg (Hcl)
131 Piroxicam10 mg
132 Prednison 5 mg
133 Primakuin15 mg
134 Prokain Benzil Penisilin Inj 3 Juta IU/vial
135 Propanolol 40 mg
136 Propil Tio Urasil100 mg
137 Ranitidin 150 mg
138 Ranitidin Injeksi 25 mg/ml
139 Retinol (Vit. A) Kapsul Lunak 100.000 IU
140 Retinol (Vit. A) Kapsul Lunak 200.000 IU
141 Ringer Laktat
142 Risperidon
143 Sabu Polivalen 5 ml (ABU I)
144 Salbutamol 2 mg
145 Salbutamol 4 mg
146 Salep 24
147 Sefiksim 100 mg
148 Semen Seng Posfat
149 Serum ATS 1500 IU / Ampul
150 Sianokobalamin Injeksi (Vit. B12) 500 MCG
151 Silver Amalgam
152 Simvastatin 10 mg
153 Siprofloksasin 500 mg
154 Skizonoat Injeksi
155 Tablet Tambah Darah Fero Fumarat 60 mg + Asam
Folat 0,4 mg
156 Temporary Stopping Fletcher Serbuk

157 Thiamin Hcl (Vit B1) Inj 100 mg/ml

158 Tiamin (Vit. B1) 50 mg
159 Triheksipenidil 2 mg
160 Trikresolformalin (TKF) Cairan
161 Ventolin Nebulizer
162 Vitamin B Kompleks
163 Zinc 20 mg
164 Zink Sirup 10 mg/ml

B. VAKSIN
1 HBU
2 DPT HB HIB
3 BCG
4 POLIO ( OPV )
5 IPV
6 CAMPAK
7 TD

C. PERBEKALAN KESEHATAN
1 Alkohol 70% 1000 ml (Afifarma)
2 Catgut Chromic 3/0 with needle
3 Catgut Plain 3/0 with needle
6 Infus Set Anak
7 Infus Set Dewasa
 8 IV Catheter 18G X 1-1/4"
9 IV Catheter 20G X 1-1/4"
10 IV Catheter 22G X 1"
11 IV Catheter 24G X 3/4"
12 Jarum Suntik
13 Kapas Pembalut 250 gram
14 Kasa Hidrofile 3 yard X 15 cm
15 Kasa Hidrofile 40 yard X 80 cm
16 Kasa Pembalut 4 Yard x 15 cm
17 Masker
23 Plester Rol Kain 5 cm X 4,5 m
24 Plester Transparant
25 Sarung Tangan Non Steril
26 Sarung Tangan Obgin Steril No. 6,5
27 Sarung Tangan Obgin Steril No. 7,0
28 Sarung Tangan Steril No. 6,5
29 Sarung Tangan Steril No. 7,0
30 Sarung Tangan Steril No. 7,5
31 Silk 3/0 with needle
34 Spuit 1 cc tb
35 Spuit 3 cc
36 Spuit 5 cc
37 Spuit 10 cc
D. TAMBAHAN
T-1 Foley Catheter 20
T-2 Softpad (Under Pad)
T-3 umblical clem
T-4 Urine Bag Sterile
T-5 Nasal Oksigen Bayi
T-6 Nasal Oksigen Anak
T-7 Nasal Oksigen Dewasa
T-8 PP INH
T-9 Glimepirid
T-10 Acetylcystein 200 mg
T-11 Sefadroxil syrup
T-12 Ketorolac Inj
T-13 Plesterin bulat soft
T-14 WIDABES
T-15 Spalk
T-16 Xylocain spray 10%
T-17 Kombipak azithromycin cefixime
T-18 Cetirizin 10 mg
T-19 Methylprednisolon 4 mg
T-20 Ondansetron inj
T-21 Ibuprofen 200mg
T-22 Kombipa FDC I
 T-23 Bayclin lar pemutih
T-24 Omeprazole 20 mg
T-25 Foley Catheter 18
T-26 Cefotaxime inj 1gr
T-27 Ketoprofen supp
T-28 Aminophilin 150 mg
T-29 Parasetamol infus
T-30 sarung tangan non steril S
T-31 sarung tangan non steril M
T-32 sarung tangan non steril L
T-33 tranexamat acid inj 5%
T-34 Amoxicilin drop
T-35 ceterizin syr
T-36 Klozapin tab
T-37 Sucralfat syr
II. JAMINAN KESEHATAN NASIONAL
1 Aminofilin inj 24 mg/ml
2 Amlodipin tablet/kapsul/kaplet 5 mg
3 Amoksisilin kapsul/kaplet/tablet scored 500 mg
4 amoxisilin 500 (novamox)
5 Amoksisilin sirup kering 125 mg/5 ml
6 Anti Bakteri DOEN Salep Kombinasi
7 Aqua pro injeksi
8 Asam asetilsalisilat (asetosal) 100 mg
9 Asam Mefenamat
10 Asiklovir 400 mg
11 Asiklovir Cream
12 Attapulgit
13 Bedak salisil serbuk 2%
14 Betahistin tablet/kapsul/kaplet 6 mg
15 Bisakodil tablet/kapsul/kaplet 5 mg
16 (Chlor Phenol Kamper Menthol (CHKM) 10 ml
Champenol)

17 Cavit 28 gr (Bahan untuk tumpatan sementara)

18 Devitalisasi Pasta Non Arsen
19 Deksametason Injeksi
20 Deksametason 0,5 mg (faridexon)
21 Dextrose 40%
22 Diazepam tab (stesolid)
23 Diazepam inj (stesolid)
24 Dipenhidramin
25 Domperidon 10 mg
26 Domperidon Sirup
27 Etil Klorida Semprot 100 ml Spray
28 Fitomenadion (Vit K1) 10 mg
29 Fitomenadion inj.
GENERIK Amoksisilin sirup kering forte 250 mg/ 5
30 ml

31 GENERIK Glimepiride tablet/kapsul/kaplet 2 mg

32 Gentamicin inj
Glass Ionomer Cemen ( Powder 15gr,Liquid 8gr
33 (6.4ml))
34 Griseofulfin Tab 125 mg
35 Hyoscine-N-butylbromide 10 mg
36 Hyoscine-N-butylbromide 20 mg/ml Injeksi
37 Hidrocortison sk
38 Kalsium Glukonat inj i.v 10%
39 Kalsium Hidroksida Pasta (Hydcal)
40 Kalsium Laktat (LIKOKALK)
41 Kaptopril tablet/ 50 mg
42 ketokonazole SK
43 Ketorolak inji 30 mg/ml
44 Klindamisin tablet/kapsul/kaplet 300 mg
45 Klorfeniramina Maleat 4 mg (CTM)
46 Klorfeniramina Maleat 4 mg (CTM) 2016
47 Kloramfenikol tetes mata 0,5%
48 kloramfenikol SM
49 kloramfenikol kapsul 250mg (microtina)
50 Klorpromazin 100 mg
51 kotrimoxazole D
52 Lidokain inj.
53 Loperamid tablet/kapsul/kaplet 2 mg
54 Metformin HCl tablet/kapsul/kaplet 500 mg
55 Metilergometrin maleat Tab 0,125 mg
56 Metilprednisolon tablet/kapsul/kaplet 4 mg
57 Metoklopramide sirup 5 mg/ 5 ml
58 Metoklopramide tablet/kapsul/kaplet 10 mg
59 MGSO4 40 Magnesium sulfat Injeksi 40%
60 Multivitamin (Betafort Sirup)
61 Multivitamin (Caviplex syrup)
62 Multivitamin (Livron B plex)
63 Mumifaying pasta ( Cresotin Paste)
64 Natrium diklofenak tablet/kapsul/kaplet 50 mg
65 Natrium klorida Infus 0,9%
66 NEODIN 10 % 300 ml
NEUROBION (Vit.B1 100 mg, vit B6 100 mg, vit
67 B12 5.000 mcg) 3ml Injeksi
68 Oksimetazolin tetes hidung 0,025%
69 Oksimetazolin tetes hidung 0,050%
70 Omeprazol tablet/kapsul/kaplet 20 mg
71 Ondansetron inj 2 mg/ml (4 mg/ 2 mL)
72 Oxitocin inj.
73 Papaverin Tablet
74 Parasetamol drips (infus) 1000 mg/100ml
75 Parasetamol sirup 120 mg / 5 ml
76 Parasetamol Tab 500 mg
77 Piracetam 800 mg
78 Piridoksin HCL Tab 10mg ( vitamin B6)
79 Piroxicam (ROSIC)
80 Prednison Tab 5 mg
81 Ranitidin 150 mg
82 Ranitidin Injeksi 25 mg/ml
83 Ringer Laktat
84 Salbutamol 2 mg (Grafalin 2 mg)
85 Salbutamol 4 mg
Salep 2-4, kombinasi: asam salisilat 2% + belerang
86 endap 4%
87 Sefadroksil sirup kering 125 mg/5 ml
88 Sefadroksil tablet/kapsul/kaplet 500 mg
89 Setirizin sirup 5 mg/5 ml
90 Setirizin tablet/kapsul/kaplet 10 mg
91 Siprofloxasin 500 mg
92 Trikresol Formalin 10 ml
93 L-Bio Sachet
94 Vitamin B Kompleks tablet (novabcomp)
95 Zinc Tablet 20 mg
96 Salon pas jet spray
97 Furosemida 40 mg
98 Alprazolam 0,5 mg
99 Parasetamol infus
100 Ketopropen supp
101 Sucralfat susp 500mg/5ml
102 Asam tranexsamat injeksi 50mg/ml
103 Domperidon tablet 10 mg
104 Ondansetron inj 2mg/ml
105 Ketokonazole 200 mg
106 Domperidon syr 5mg/5ml
107 Amoksisilin sirup 250 mg
108
109
B. PERBEKALAN KESEHATAN
1 Infus Set Anak
2 IV Catheter 18G X 1-1/4"
3 IV Catheter 20G X 1-1/4"
 4 IV Catheter 22G X 1"
5 IV Catheter 24G X 3/4"
6 AXIMED FACK MASK TIES ON
7 Sarung Tangan Non Steril Ukuran L
8 Sarung Tangan Non Steril Ukuran M
9 Infus Set Dewasa
10 Sarung Tangan Steril Ukuran 6,5
11 Sarung Tangan Steril Ukuran 7,0
12 Sarung Tangan Steril Ukuran 7,5
13 NASAL OXYGEN, O2 cannula, size XS (Bayi)
14 NASAL OXYGEN, O2 cannula, size S (Anak)
15 NASAL OXYGEN, O2 cannula, size M (Dewasa)
16 Kasa Hidrofile 40 yard x 80 cm
17 Kasa Hidrofile 3 yard x 15 cm (PACK/50 pc)
Spuit 1 cc (NIPRO Syringe 1cc Tuberculin with
18 Needle 26GX1/2" E Beam Sterilization)

Spuit 3 cc (NIPRO Syringe 3cc Luer Lock With

19 Needle 23GX1-1/4" Elektron Beam Sterilization)

Spuit 5 cc (NIPRO Syringe 5cc Luer Lock With

20 Needle 22GX1-1/2" Elektron Beam Sterilization)

Spuit 10 cc (NIPRO Syringe 10cc Luer Lock With

21 Needle 21GX1-1/2" Elektron Beam Sterilization)

22 Silk 3/0 + Jarum 1/2 GT 35 mm

23 Kapas Pembalut 250g
24 Masker N95
25 Urine Bag Sterile
26 My Jelly 82 gram
27 My Jelly 5 gram steril
28 Sabun Aseptic Gel 500 cc + dispenser
29 Sabun Anti Bakteri 500 ml + disp
30 Onemed Asept 500 ml
31 Odex 500 ml
32 Aseptan 500 cc + pump
33 Onescrub 2% 100 ml
34 Onescrub 500 cc + dispenser
35 Onescrub 5 liter
36 Softpad (Underpad) 60 x 90 cm Non Steril
37 USG Gel 250 ml
38 USG Gel 5 L
39 Sarung Tangan Obgyn Steril ( Obgyn glove)
40 Alkohol 70% 1000 ml
41 Twist Blood Lancet
42 Alcohol Swab
43 Benang Operasi Plain Catgut With Needle 3.0
44 Benang Operasi Cromic Catgut With Needle 3.0
45 Foley Catether 2 Way Fr. 18 (Box/10pcs)
46 Foley Catether 2 Way Fr. 20 (Box/10pcs)
47 Plester Rol Kain 5 cm x 4.5 m
48 Gelang Pasien (Merah muda)
49 Gelang Pasien (Biru)
50 Gelang Pasien (Kuning)
51 Masker Nebulizer Anak
52 Masker Nebulizer Dewasa
53 Chlorin 1000 ml
54 Jarum Suntik 23 G
55 Kertas Puyer 500 Lembar
56 Klip Obat Sablon Besar
57 Klip Obat Sablon Kecil
58 Klip Obat Sablon Sedang
59 Steril Scapel Blades No.11
60 Pembersih Lantai 800 ml Refill
61 Perhidrol ( H2O2 ) 3% 1000 ml
62 Spalk First Aid
63 Tissu 250 sheet
64 Spiritus 1000 ml
65 Pengharum Ruangan 250 ml
66 Klem Tali Pusar

1 JAYAMAS Onemed Catgut Plain 3/0 + Jarum 1/2

GT35 mm
2 JAYAMAS Onemed Catgut Chromic 3/0 + jarum
1/2 GT 35 mm
3 JAYAMAS Onemed My Jelly 5 gram steril
4
JAYAMAS Onemed Aseptic Gel 500 cc + dispenser
5
JAYAMAS Onemed OneScrub 500 cc + dispenser
6 JAYAMAS Onemed OneScrub 5 liter
7 JAYAMAS Onemed USG Gel 250ml
8 JAYAMAS Onemed USG Gel 5L
9 JAYAMAS Onemed Lysol 1 Liter
10 JAYAMAS Onemed Surgical Mask Plus 3 Ply Plus
Earloop
11 Aximed EXAMINATION GLOVES, size S
12 Aximed STOMACH TUBE, 85cm, no. 18
13 Aximed FEEDING TUBE, 100cm, no. 8
14 Aximed FEEDING TUBE, 40cm, no. 8
15 Kertas Puyer 500 Lembar
16 Klip Obat Sablon Besar
17 Klip Obat Sablon Sedang
18 Steril Scapel Blades No.11
19 Pembersih Lantai 800 ml Refill
20 Perhidrol ( H2O2 ) 3% 1000 ml
21 Spalk First Aid
22 Pengharum Ruangan 250 ml refill matic
23 Bahan Pengharum ruangan
24 Tisue gulung
25 Kertas USG
26 kantong puyer
27 Kartu gol darah
28 Maternity Softex
29 Tabung EDTA
30 Jarum Vacutainer
31
32
5 6 7 8 9 10 11 12 13
14 15 16 17 18 19 20 21 22
23 24 25 26 27 28 29 30 31
TOTAL

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
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0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0