Pencacahan 31 Des 18 REVISI METODE PERHITUNGAN PART 3

LAMPIRAN BERITA ACARA PENCACAHAN OBAT DI UPTD IFK DOMPU
PERIODE 31 DESEMBER 2018
TANGGAL HARGA
NO NAMA OBAT SATUAN PRODUSEN JUMLAH SUMBER DANA NO. BATCH NILAI PERSEDIAAN
KADALUARSA SATUAN
NILAI TOTAL PERSEDIAAN 5,496,504,043.70
DANA APBN 909,904,288.00
Bahan Medis Habis Pakai 437,835,360.00

1 Anti - HIV 1/2 Test ONE STEP - Bio Line Paket Depkes 3 PROGRAM D3AMC002A 01/08/2019 1,434,000.00 4,302,000.00
2 Catgut Plain Pcs PT. Jayamas Medica Industri 24 APBN 2018 615134 01/07/2021 54,166.67 1,300,000.00
3 Hepatitis B Imunoglobin (Hb Ig) Vial Depkes 50 APBN 2018 H2MAB00083 18/08/2020 1,300,000.00 65,000,000.00
4 Hexagon Syphillis Rapid Test Paket Depkes 600 PROGRAM 17011 01/06/2019 534,160.00 320,496,000.00
5 Masker ties on Pcs PT. Jayamas Medica Industri 2,650 APBN 2018 08081687 01/12/2020 330.00 874,500.00
6 Plester 5 yard x 2 inc (Hansaplast) Rol PT. Beiersctorf Indo 50 APBN 2018 71815448 01/05/2020 25,404.00 1,270,200.00
Plester 5 yard x 2 inc (Hansaplast) Rol PT. Beiersctorf Indo 300 APBN 2018 72946648 01/07/2020 20,332.20 6,099,660.00
7 Rapid Test HBsAg WB Pcs Depkes 3,900 APBN 2018 01EMC0181 01/07/2020 9,870.00 38,493,000.00
Obat - Obatan 462,869,128.00

1 Albendazole 400 mg Tablet PT. Indofarma 52,920 APBN 2018 1802014 01/03/2021 424.00 22,438,080.00
Albendazole 400 mg Tablet PT. Indofarma 153,090 APBN 2018 1804028 01/04/2021 424.00 64,910,160.00
Albendazole 400 mg Tablet PT. Indofarma 2,100 APBN 2018 1804049 01/04/2021 424.00 890,400.00
2 Anti Malaria (DHP) Kotak 9's Depkes 5 APBN 2018 170412 01/04/2019 31,482.00 157,410.00
Anti Malaria (DHP) Kotak 9's Depkes 78 APBN 2018 170503 01/05/2019 31,482.00 2,455,596.00
3 Cotrimoxazol 480 mg Tablet PT. Novapharin 8,700 APBN 2016 161102123 01/11/2020 165.00 1,435,500.00
4 Diazepam 5 mg Tablet PT. Kimia Farma 4,200 APBN 2018 A80480 01/02/2022 109.00 457,800.00
5 Garam Oralit Sachet PT. Kimia Farma 200 APBN 2018 G81460B 01/06/2023 263.00 52,600.00
Garam Oralit Sachet PT. Kimia Farma 1,000 APBN 2018 H81461B 01/07/2023 263.00 263,000.00
Garam Oralit Sachet PT. Kimia Farma 18,000 APBN 2018 H81466B 01/07/2023 263.00 4,734,000.00
6 Haloperidol Dekanoat Inj 50mg/ml Ampul PT. Soho Industri Pharmasi 30 APBN 2018 6009 01/10/2019 97,500.00 2,925,000.00
7 Ibuprofen 400 mg Tablet PT. Phyto Kemo Agung 10,000 APBN 2018 BB911927 01/02/2021 130.00 1,300,000.00
8 Isoniazid Tablet Lupin 2,500 PROGRAM A4D0517B 01/09/2019 75.00 187,500.00
9 MDT Combi Dewasa Paket Depkes 27 PROGRAM BHE6751 01/03/2021 189,420.00 5,114,340.00
10 Metronidazol 500 mg Tablet PT. Phyto Kemo Agung 1,500 APBN 2016 ZJ912610 01/10/2019 160.00 240,000.00
11 Mineral Mix Sachet Depkes 230 APBN 2017 1707017 01/07/2019 2,550.00 586,500.00
12 OAT Kat. 1,3 Paket Depkes 151 APBN 2017 K60167J 01/11/2019 377,980.00 57,074,980.00
13 OAT Kat. Anak Paket Depkes 9 APBN 2018 E81354J 01/03/2021 244,144.00 2,197,296.00
OAT Kat. Anak Paket Depkes 6 APBN 2018 16490328 01/06/2020 232,518.00 1,395,108.00
13 OAT Kat. II Paket PT. Phapros 12 APBN 2018 16471003-1 01/12/2020 1,362,784.00 16,353,408.00
14 Piroxicam 20 mg Tablet PT. Triman 4,000 APBN 2018 D7019 01/04/2020 98.00 392,000.00
15 Retinol 200.000 IU (Merah) Kapsul Lunak PT. Kimia Farma 220,500 APBN 2018 086152W 01/08/2019 531.00 117,085,500.00
Retinol 200.000 IU (Merah) Kapsul Lunak PT. Kimia Farma 188,000 APBN 2018 H71975W 01/08/2020 531.00 99,828,000.00
16 Tablet Tambah Darah Tablet PT. Phapros 15,360 APBN 2018 06818102 01/10/2019 375.00 5,760,000.00
Tablet Tambah Darah Tablet PT. Phapros 810 APBN 2019 06818076 4/1/2019 375.00 303,750.00
17 Zinc 20 mg Tablet PT. Indofarma 100,800 APBN 2017 1708017 01/07/2020 539.00 54,331,200.00
Page 1 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Injeksi dan Pelarut 6,079,800.00

1 Artesunat Injeksi Vial Guilin Pharmaceutical Co.,LDT 22 APBN 2017 LA16518 14/03/2019 40,900.00 899,800.00
2 Haloperidol Dekanoat Injection 50 mg/ml Ampul PT. Soho Industri Pharmasi 30 APBN 2017 6009 01/10/2019 97,500.00 2,925,000.00
3 Magnesium Sulfat 20% Vial PT. Otsuka 410 APBN 2014 90G44 21/07/2019 5,500.00 2,255,000.00
Tetes Mata, Tetes Telinga, Salep dan Sed. Topikal 3,120,000.00

1 Oxytetrasiklin Salep Mata 0,1% Tube PT. Kimia Farma 1,200 APBN 2018 18242026W 01/09/2021 2,600.00 3,120,000.00
DANA DAK 4,586,599,755.70

Bahan Medis Habis Pakai 1,034,898,630.86
1 Alat Suntik sekali pakai 0,5 ml Pcs Abu Dhabi Medical Devices 5,900 DAK 2017 031738 01/06/2022 1,877.00 11,074,300.00
2 Alat Suntik sekali pakai 1 ml Pcs Aximed - Shanghai Kindly 800 DAK 2018 1110 09/11/2021 1,170.00 936,000.00
Alat Suntik sekali pakai 1 ml Pcs Aximed - Shanghai Kindly 200 DAK 2017 0310 09/03/2022 1,200.00 240,000.00
Alat Suntik sekali pakai 1 ml Pcs PT. Anugrah Mitra Selaras 4,290 DAK 2018 1110 09/11/2022 1,170.00 5,019,300.00
3 Alat Suntik sekali pakai 3 ml Pcs Remedi 16,300 DAK 2018 1110 09/11/2022 956.00 15,582,800.00
4 Alat Suntik sekali pakai 5 ml Pcs Aximed - Shanghai Kindly 5,600 DAK 2016 20150830 01/07/2020 1,011.52 5,664,512.00
Alat Suntik sekali pakai 5 ml Pcs Remedi 10,000 DAK 2018 0110 09/01/2023 1,228.50 12,285,000.00
7 Blade Sterile (Mess) Pcs PT. Advance Medicare Corpora 590 DAK 2018 7259 01/06/2022 11,211.63 6,614,861.70
Blade Sterile (Mess) Pcs PT. Advance Medicare Corpora 8,200 DAK 2018 8119 01/03/2023 11,211.63 91,935,366.00
8 Blood Transfusion Set Pcs PT. Anugrah Mitra Selaras 444 DAK 2017 01041688 01/02/2022 5,880.00 2,610,720.00
9 Catgut Chromic (Absorbable Suture Sterile) Pcs PT. Jayamas Medica Industri 6,000 DAK 2018 1709215 01/09/2022 6,141.67 36,850,020.00
10 Catgut Rol Lyofil Rol Bio Dinamics Germany 24 DAK 2016 03351 01/12/2020 956,894.40 22,965,465.60
11 Catgut Plain Pcs PT. Jayamas Medica Industri 168 DAK 2017 1709215 01/09/2022 6,141.67 1,031,800.56
12 Cathejell® Lidocain Pcs Pharm Fabrik Montavit Get 90 DAK 2018 4361 01/07/2020 43,680.00 3,931,200.00
Cathejell® Lidocain Pcs Pharm Fabrik Montavit Get 125 DAK 2018 4561 01/09/2020 43,680.00 5,460,000.00
Cathejell® Lidocain Pcs Pharm Fabrik Montavit Get 5 DAK 2016 11771 01/03/2021 44,100.00 220,500.00
13 Dermafix T 10X12 cm Pcs PT. Jayamas Medica Industri 97 DAK 2018 30071888 01/06/2023 6,624.00 642,528.00
14 Female Catheter no. 12 Pcs PT. Jayamas Medica Industri 71 DAK 2018 08051488 01/04/2019 5,324.00 378,004.00
15 Female Catheter no. 16 Pcs Aximed - Suzhou Weikang 81 DAK 2018 20170820 01/08/2022 7,092.80 574,516.80
16 Foley Catheter no. 18 Pcs PT. Jayamas Medica Industri 52 DAK 2018 16-G-15D 01/03/2021 8,800.00 457,600.00
Foley Catheter no. 18 Pcs PT. Anugrah Mitra Selaras 176 DAK 2017 1611021814 01/10/2021 11,040.00 1,943,040.00
18 Gel Dopler USG Botol PT. Multiguna 20 DAK 2018 D0616013 01/06/2021 182,701.08 3,654,021.60
19 Infus Set Anak Pcs Stera 8,500 DAK 2018 11091788 01/08/2022 3,850.00 32,725,000.00
20 Infus Set Dewasa Pcs Stera 8,400 DAK 2018 02061788 01/04/2021 3,520.00 29,568,000.00
21 IV Catheter no. 16 Pcs PT. Denar Dana Djaya 450 DAK 2018 160201 01/02/2019 7,775.00 3,498,750.00
Page 2 of 54
TANGGAL HARGA
KADALUARSA SATUAN
IV Catheter no. 16 Pcs PT. Otsuka 200 DAK 2016 30036 01/03/2021 8,470.00 1,694,000.00
22 IV Catheter no. 18 Pcs PT. Denar Dana Djaya 4,600 DAK 2018 180131 01/03/2021 7,885.00 36,271,000.00
IV Catheter no. 18 Pcs PT. Anugrah Mitra Selaras 500 DAK 2017 3006217A 01/12/2021 5,040.00 2,520,000.00
23 IV Catheter no. 20 Pcs Remedi 11,250 DAK 2017 3039917B 01/01/2022 5,040.00 56,700,000.00
IV Catheter no. 22 Pcs PT. Anugrah Mitra Selaras 3,550 DAK 2017 3326416N 01/11/2021 5,040.00 17,892,000.00
26 Jarum Kulit GT 14 Bungkus PT. Ridho Ilahi Farma 3,432 DAK 2018 1,500.00 5,148,000.00
27 Jarum Otot GR 14 Bungkus PT. Ridho Ilahi Farma 3,336 DAK 2018 1,500.00 5,004,000.00
28 Kapas Pembalut Bungkus PT. Jayamas Medica Industri 845 DAK 2017 01091688 01/10/2021 13,750.00 11,618,750.00
29 Kassa Hidrofil Panjang Rol PT. Anugrah Mitra Selaras 694 DAK 2018 1803 3/1/2023 123,375.00 85,622,250.00
30 Kassa Hidrofil Steril 16x16 cm Kotak PT. Jayamas Medica Industri 1,260 DAK 2016 19101588 01/09/2020 6,380.00 8,038,800.00
31 Masker N95/R10 Pcs Kimberly Clark China 920 DAK 2016 MASKERN95 01/12/2030 21,450.00 19,734,000.00
32 Masker Rebreathing Pcs Besmed Health Bussiness 25 DAK 2018 22011888 01/12/2030 27,104.00 677,600.00
Masker Rebreathing Pcs Besmed Health Bussiness 26 DAK 2018 27121388 01/12/2030 27,104.00 704,704.00
33 Masker ties on Pcs PT. Vasmedica Spundbond 2,500 DAK 2018 001001001 16/11/2022 753.33 1,883,325.00
34 Nasal Canula Anak Pcs Stardec - WL Medical co. Ltd 25 DAK 2016 1511021916 01/10/2020 10,000.00 250,000.00
Nasal Canula Anak Pcs PT. Jayamas Medica Industri 26 DAK 2018 10101788 01/12/2030 6,050.00 157,300.00
35 Nasal Canula Dewasa Pcs Stardec - WL Medical co. Ltd 2 DAK 2016 1605020768 01/04/2021 10,000.00 20,000.00
Nasal Canula Dewasa Pcs PT. Jayamas Medica Industri 40 DAK 2018 3041788 01/12/2030 6,050.00 242,000.00
36 Needle No. 25G x 25 mm Pcs PT. Terumo Medical Product 2,200 DAK 2018 161020 01/09/2021 346.50 762,300.00
Needle No. 25G x 25 mm Pcs 3,300 DAK 2018 180120 31/12/2022 346.50 1,143,450.00
37 Plester Pharmafix Pcs Pharmaplast Amaria Egypt 737 DAK 2016 10B16 01/02/2021 29,700.00 21,888,900.00
38 Plester 5 yard x 2 inc (Hansaplast) Rol PT. Beiersctorf Indo 89 DAK 2018 73754648 01/09/2020 26,244.00 2,335,716.00
Plester 5 yard x 2 inc (Hansaplast) Rol PT. Beiersctorf Indo 42 DAK 2018 81251848 01/03/2021 26,244.00 1,102,248.00
39 Sarung Tangan Latex Powder no. S Pcs Multisave Sdn Bhd 1,300 DAK 2017 1000542505 01/10/2019 748.71 973,323.00
Sarung Tangan Latex Powder no. S PT. Alexa Medica 5,000 DAK 2018 219052636LCZA 01/12/2022 657.80 3,289,000.00
40 Sarung Tangan Latex Powder no. M Pcs PT. Alexa Medica 9,500 DAK 2018 211042636LCZA 01/09/2022 657.80 6,249,100.00
41 Sarung Tangan Latex Powder no. L Pcs PT. Alexa Medica 4,000 DAK 2018 211047941LCZA 01/09/2022 657.80 2,631,200.00
42 Sarung Tangan Non Steril L Pcs Aximed - Zhejiang Kindly Medical 6,100 DAK 2016 1603033 24/01/2021 1,007.16 6,143,676.00
43 Sarung Tangan Non Steril M Pcs Aximed - Zhejiang Kindly Medical 39,800 DAK 2016 1603012 09/02/2021 1,007.16 40,084,968.00
44 Sarung Tangan Obgyn Pcs PT. Anugrah Mitra Selaras 640 DAK 2017 17035181 01/01/2022 20,880.00 13,363,200.00
45 Sarung Tangan Steril no. 7 Pcs Aximed - Zhejiang Kindly Medical 6,950 DAK 2016 16160311 01/05/2021 8,284.00 57,573,800.00
46 Sarung Tangan Steril no. 7,5 Pcs Aximed - Zhejiang Kindly Medical 6,600 DAK 2016 16160311 01/05/2021 8,284.00 54,674,400.00
47 Scalvin no. 25 (Wing Needle) Pcs PT. Jayamas Medica Industri 151 DAK 2016 25072014 01/06/2019 1,540.00 232,540.00
48 Silk 3/0 (Silk Braided Non Absorbable Suture Sterile) Pcs PT. Jayamas Medica Industri 23,508 DAK 2017 1608170 01/08/2021 3,361.11 79,012,973.88
49 Silk Rol (Silk Black Braided 3/0 2 metric 100 m) Rol Bio Dinamics Germany 31 DAK 2016 003161 01/12/2019 409,065.30 12,681,024.30
50 Stomach tube no. 12 Pcs PT. Terumo Medical Product 28 DAK 2015 140224B 01/01/2019 9,099.00 254,772.00
Stomach tube no. 18 Pcs PT. Bio Axion 26 DAK 2018 20170715 01/07/2022 9,138.47 237,600.22
52 Under Pad (Soft Pad 60 x 90 cm) Pcs PT. Jayamas Medica Industri 12,430 DAK 2017 UNDERPAD17 01/12/2030 4,578.54 56,911,252.20
53 Urine Bag Pcs PT. Jayamas Medica Industri 330 DAK 2017 03031788 01/02/2022 3,300.00 1,089,000.00
Page 3 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Obat - Obatan 1,936,743,880.00

1 Acyclovir 400 mg Tablet PT. Indofarma 123,400 DAK 2016 1606044 01/07/2020 366.00 45,164,400.00
2 Allopurinol 100 mg Tablet PT. Rama Emerald Multi Sukses 32,800 DAK 2017 T11051 AF 01/11/2019 93.00 3,050,400.00
Allopurinol 100 mg Tablet PT. Novapharin 70,000 DAK 2018 1808-02-106 01/08/2020 194.00 13,580,000.00
3 Amitryptylline 25 mg Tablet PT. Parit Padang Global 15,000 DAK 2018 A1402AV 01/01/2022 168.00 2,520,000.00
4 Amlodipin 10 mg Tablet PT. Pharma Laboratories 24,330 DAK 2018 HL098145 01/11/2020 95.00 2,311,350.00
Amlodipin 10 mg Tablet PT. Pharma Laboratories 22,560 DAK 2018 AE09H007 01/05/2021 95.00 2,143,200.00
5 Amoxicillin 500 mg Tablet PT. Hexapharm Jaya 4,000 DAK 2018 CAMXA80513 01/07/2020 245.00 980,000.00
Amoxicillin 500 mg Tablet PT. Mersi 192,000 DAK 2018 B80134 01/08/2020 245.00 47,040,000.00
Amoxicillin 500 mg Tablet PT. Hexapharm Jaya 24,000 DAK 2018 CAMXA80382 01/04/2021 245.00 5,880,000.00
Amoxicillin 500 mg Tablet PT. Pharma Laboratories 343,400 DAK 2017 HJ018430 01/09/2021 191.00 65,589,400.00
Amoxicillin 500 mg Tablet PT. Pharma Laboratories 90,000 DAK 2017 HK018457 01/10/2021 191.00 17,190,000.00
6 Antasida DOEN Tablet Tablet PT. Triman 161,900 DAK 2018 D8021 01/04/2021 160.00 25,904,000.00
Antasida DOEN Tablet Tablet PT. Triman 260,000 DAK 2018 E8022 01/05/2021 160.00 41,600,000.00
7 Asam Ascorbat 250 mg Tablet PT. Tempo Scan Pasific 5,000 DAK 2017 80027 01/08/2019 115.00 575,000.00
8 Asam Ascorbat 50 mg Tablet PT. Kimia Farma 183,400 DAK 2018 E80078BI 01/04/2021 110.00 20,174,000.00
9 Asam Folat 1 mg Tablet PT. Marin Liza Farmasi 7,800 DAK 2018 18TC024 01/03/2020 74.00 577,200.00
10 Asam Mefenamat 500 mg Tablet PT. Mersi 264,400 DAK 2018 A80515 01/03/2020 103.00 27,233,200.00
Asam Mefenamat 500 mg Tablet PT. Holi Pharma 94,500 DAK 2017 1708207 01/08/2020 219.00 20,695,500.00
11 Asetosal 80 mg (Miniaspi) Tablet PT. Mersifarma 4,300 DAK 2018 A80832 01/02/2020 99.00 425,700.00
Asetosal 80 mg (Miniaspi) Tablet PT. Mersifarma 11,500 DAK 2016 160315 01/04/2020 155.00 1,782,500.00
12 Asetyl Sistein 200 mg Kapsul PT. Indofarma 34,500 DAK 2018 18ASI009 01/04/2020 376.00 12,972,000.00
Asetyl Sistein 200 mg Kapsul PT. Indofarma 132,000 DAK 2018 18ASI019 01/05/2020 376.00 49,632,000.00
Asetyl Sistein 200 mg Kapsul PT. Indofarma 60 DAK 2017 1705096 6/1/2019 376.00 22,560.00
13 Attapulgit 600 mg (Pularex) Tablet PT. Zenith Pharmaceuticals 71,400 DAK 2016 12204606 01/04/2020 210.00 14,994,000.00
Attapulgit 600 mg (Pularex) Tablet PT. Zenith Pharmaceuticals 10,000 DAK 2016 7G355318 01/07/2022 210.00 2,100,000.00
14 Calcium Lactate 500 mg Tablet PT. Yekatria Farma 17,000 DAK 2015 4BC021 01/08/2019 59.00 1,003,000.00
Calcium Lactate 500 mg Tablet PT. Mersifarma 250,000 DAK 2018 A80168 01/04/2020 59.00 14,750,000.00
15 Captopril 12,5 mg Tablet PT. Kimia Farma 10,000 DAK 2018 D80692B 01/03/2023 65.00 650,000.00
16 Captopril 25 mg Tablet PT. Kimia Farma 26,900 DAK 2016 C160191B 01/03/2021 71.00 1,909,900.00
Captopril 25 mg Tablet PT. Errita Pharma 4,500 DAK 2017 IH1796 01/03/2021 154.00 693,000.00
Captopril 25 mg Tablet PT. Errita Pharma 210,000 DAK 2017 JH1911 01/04/2021 154.00 32,340,000.00
Captopril 25 mg Tablet PT. Phapros 5,000 DAK 2017 06324017 01/08/2022 154.00 770,000.00
17 Carbamazepin 200 mg Tablet PT. Mersifarma 24,500 DAK 2017 171673 01/08/2019 231.00 5,659,500.00
Carbamazepin 200 mg Tablet PT. Mersifarma 69,600 DAK 2018 A80702 01/03/2020 231.00 16,077,600.00
18 Cavicur Tablet PT. Erla 1,200 DAK 2018 H0753017 01/04/2021 655.00 786,000.00
Cavicur Tablet PT. Erla 19,200 DAK 2018 H0753020 01/05/2021 655.00 12,576,000.00
19 Chloramphenicol 500 mg (Chloramex) Kapsul PT. Actavis 48,900 DAK 2016 T2388140 01/07/2019 1,056.00 51,638,400.00
20 Chlorpheniramin Maleat (CTM) 4 mg Tablet PT. PIM Pharmaceuticals 109,800 DAK 2017 09709004 01/09/2020 60.00 6,588,000.00
Chlorpheniramin Maleat (CTM) 4 mg Tablet PT. Trifa Raya Laboratories 166,400 DAK 2016 1608144 01/08/2021 53.00 8,819,200.00
21 Chlorpromazin 100 mg Tablet PT. Mersifarma 30,900 DAK 2018 A80221 01/02/2022 605.00 18,694,500.00
22 Ciprofloxacin 500 mg Tablet PT. Novapharin 59,700 DAK 2016 1607-62-108 01/07/2020 289.00 17,253,300.00
Ciprofloxacin 500 mg Tablet PT. Novapharin 10,000 DAK 2018 1807-16-108 31/07/2020 272.00 2,720,000.00
Page 4 of 54
TANGGAL HARGA
KADALUARSA SATUAN
23 Clindamycin 150 mg Tablet PT. Novell 6,750 DAK 2018 EBG021 01/07/2020 729.00 4,920,750.00
24 Cotrimoxazol 480 mg Tablet PT. Rama Emerald Multi Sukses 362,600 DAK 2016 T3107AF 01/08/2019 154.00 55,840,400.00
25 Dexamethasone 0,5 mg Tablet PT. Novapharin 106,200 DAK 2018 1807-33-150 31/07/2020 33.00 3,504,600.00
Dexamethasone 0,5 mg Tablet PT. Promedrahardjo Farmasi Industri 176,500 DAK 2017 00717H0320 01/08/2020 43.00 7,589,500.00
26 Diazepam 2 mg Tablet PT. Kimia Farma 93,900 DAK 2018 B802019 01/02/2021 115.00 10,798,500.00
27 Digoxin 0,25 mg Tablet PT. Yarindo Farma 300 DAK 2016 A7805BT 01/02/2020 106.00 31,800.00
Digoxin 0,25 mg Tablet PT. Yarindo Farma 3,000 DAK 2018 A8602BV 01/02/2020 104.00 312,000.00
28 Dimenhydrinat 50 mg Tablet PT. Kimia Farma 7,500 DAK 2018 D80810B 01/03/2023 110.00 825,000.00
29 Domperidon 10 mg Tablet PT. Novapharin 3,900 DAK 2016 1711-02-149 01/11/2019 170.00 663,000.00
Domperidon 10 mg Tablet PT. Novapharin 103,500 DAK 2016 1604-09-149 01/04/2020 170.00 17,595,000.00
30 Doxycycline 100 mg Kapsul PT. Indofarma 124,500 DAK 2016 1604009 01/05/2020 282.00 35,109,000.00
31 Erytromycin 250 mg Tablet PT. Lucas Djaja 2,700 DAK 2018 18CD016 01/02/2021 576.00 1,555,200.00
Erytromycin 250 mg Tablet PT. Lucas Djaja 44,200 DAK 2018 18CC001 01/03/2021 576.00 25,459,200.00
Erytromycin 250 mg Tablet PT. Lucas Djaja 100 DAK 2018 18CD024 01/04/2021 576.00 57,600.00
32 Erytromycin 500 mg Tablet PT. Rama Emerald Multi Sukses 22,500 DAK 2017 T07075AG 01/01/2021 751.00 16,897,500.00
Erytromycin 500 mg Tablet PT. Rama Emerald Multi Sukses 20,000 DAK 2017 T04038AH 01/10/2021 751.00 15,020,000.00
33 Furosemide 40 mg Tablet PT. Sampharindo Perdana 2,200 DAK 2017 FE2471 01/05/2021 81.00 178,200.00
Furosemide 40 mg Tablet PT. Kimia Farma 6,400 DAK 2018 C80551B 01/02/2021 79.00 505,600.00
34 Glibenclamide 5 mg Tablet PT. Indofarma 107,000 DAK 2018 1701009 01/04/2022 125.00 13,375,000.00
Glibenclamide 5 mg Tablet PT. Indofarma 2,000 DAK 2018 1707038 01/11/2022 125.00 250,000.00
Glibenclamide 5 mg Tablet PT. Indofarma 48,000 DAK 2018 1710068 01/01/2023 125.00 6,000,000.00
35 Glimepiride 1 mg Tablet PT. OGB Dexa 9,400 DAK 2018 49F0044 01/05/2021 174.00 1,635,600.00
Glimepiride 1 mg Tablet PT. OGB Dexa 60,300 DAK 2018 49G0068 01/07/2021 174.00 10,492,200.00
37 Griseofulvin 500 mg Tablet PT. Mensa Bina Sukses 10,000 DAK 2018 AJ12H005 01/09/2020 892.00 8,920,000.00
38 Haloperidol 0,5 mg Tablet PT. Holi Pharma 200 DAK 2016 1505029 01/07/2020 61.00 12,200.00
Haloperidol 0,5 mg Tablet PT. Holi Pharma 6,000 DAK 2017 1703003 01/03/2020 62.00 372,000.00
39 Haloperidol 1,5 mg Tablet PT. Holi Pharma 6,800 DAK 2018 A1909DV 01/04/2023 59.00 401,200.00
40 Haloperidol 5 mg Tablet PT. Indofarma 61,200 DAK 2016 1504027 01/05/2019 100.00 6,120,000.00
41 Hydrochlorthiazide 25 mg Tablet PT. Kimia Farma 12,200 DAK 2016 E160426B 01/05/2021 156.00 1,903,200.00
42 Ibuprofen 200 mg Tablet PT. Novapharin 335,000 DAK 2018 1807-39-177 01/07/2020 108.00 36,180,000.00
44 Isosorbide Dinitrate 5 mg Tablet PT. Indofarma 500 DAK 2016 1603006 01/04/2020 93.00 46,500.00
45 Ketoconazole 200 mg Tablet PT. OGB Dexa 11,350 DAK 2015 2761255 01/06/2019 300.00 3,405,000.00
Ketoconazole 200 mg Tablet PT. Novapharin 30,000 DAK 2018 1806-01-103 01/06/2020 286.00 8,580,000.00
46 Kombipak (Azythromycin + Cefixime) Kotak PT. Kimia Farma 195 DAK 2018 F81832J1 01/09/2020 31,231.00 6,090,045.00
47 Loratadine 10 mg Tablet PT. Promedrahardjo Farmasi Industri 266,700 DAK 2018 10218E0020 01/05/2021 125.00 33,337,500.00
48 Metformin 500 mg Tablet PT. Tempo Scan Pasific 84,500 DAK 2017 0607271 01/06/2019 99.00 8,365,500.00
49 Metformin 500 mg Tablet PT. Hexapharm Jaya 100,000 DAK 2018 HTMFNA82699 31/03/2020 99.00 9,900,000.00
50 Methyl Ergometrine 0,125 mg Tablet PT. Kimia Farma 1,300 DAK 2018 D81056J 01/04/2023 221.00 287,300.00
51 Methyl Prednisolone 4 mg Tablet PT. Molex Ayu 14,500 DAK 2017 ZS147 01/09/2020 160.00 2,320,000.00
Methyl Prednisolone 4 mg Tablet PT. Molex Ayu 100,000 DAK 2018 MO2AA015 01/04/2021 137.00 13,700,000.00
52 Metoclopramide 10 mg Tablet PT. Graha Farma 2,500 DAK 2018 WK377G 01/11/2020 80.00 200,000.00
53 Metronidazole 250 mg Tablet PT. Phyto Kemo Agung 28,900 DAK 2017 BG912718 01/07/2021 96.00 2,774,400.00
Page 5 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Metronidazole 250 mg Tablet PT. Phyto Kemo Agung 21,000 DAK 2018 BK912712 01/11/2021 91.00 1,911,000.00
54 Metronidazole 500 mg Tablet PT. Phyto Kemo Agung 51,100 DAK 2015 ZD91267 01/04/2019 164.00 8,380,400.00
Metronidazole 500 mg Tablet PT. Phyto Kemo Agung 300 DAK 2015 ZI912610 01/10/2019 164.00 49,200.00
55 Natrium Diclofenac 25 mg Tablet PT. Phapros 144,600 DAK 2018 16364022 01/06/2023 132.00 19,087,200.00
56 Natrium Diclofenac 50 mg Tablet PT. Phapros 3,800 DAK 2018 06365045 01/12/2020 127.00 482,600.00
Natrium Diclofenac 50 mg Tablet PT. Phapros 51,700 DAK 2018 16365021 01/04/2021 127.00 6,565,900.00
57 Nifedipin 10 mg Tablet PT. OGB Dexa 9,700 DAK 2017 48D4190 01/03/2021 110.00 1,067,000.00
Nifedipin 10 mg Tablet PT. Kimia Farma 13,000 DAK 2018 D80821B 01/04/2022 198.00 2,574,000.00
58 Nystatin 100.000 IU Tablet Vaginal Tablet PT. Phapros 3,200 DAK 2018 06272013 01/11/2021 590.00 1,888,000.00
59 Nystatin 500.000 IU Tablet PT. Phapros 200 DAK 2018 16371003 01/04/2021 830.00 166,000.00
60 Omeprazole 20 mg Kapsul PT. Novapharin 27,840 DAK 2016 1606-03-53 01/06/2020 216.00 6,013,440.00
Omeprazole 20 mg Kapsul PT. Novapharin 102,600 DAK 2018 1807-18-53 01/07/2020 134.00 13,748,400.00
61 Paracetamol 500 mg Tablet PT. PIM Pharmaceuticals 100 DAK 2017 06711023 01/11/2022 164.00 16,400.00
Paracetamol 500 mg Tablet PT. PIM Pharmaceuticals 13,100 DAK 2018 05802028 01/02/2023 160.00 2,096,000.00
Paracetamol 500 mg Tablet PT. PIM Pharmaceuticals 1,300 DAK 2018 05804095 01/04/2023 160.00 208,000.00
62 Phenobarbital 30 mg Tablet PT. Kimia Farma 186,500 DAK 2016 G160759B 01/07/2019 132.00 24,618,000.00
63 Phytomenadion 10 mg Tablet PT. Phapros 14,000 DAK 2016 16381002 01/03/2021 747.00 10,458,000.00
64 Prednisone 5 mg Tablet PT. Holi Pharma 186,500 DAK 2018 1801097 01/01/2020 72.00 13,428,000.00
65 Primaquin 15 mg Tablet PT. Phapros 188,500 DAK 2016 95386004 01/08/2019 235.00 44,297,500.00
66 Propanolol 10 mg Tablet PT. Holi Pharma 6,000 DAK 2017 1706002 01/06/2019 66.00 396,000.00
Propanolol 10 mg Tablet PT. Holi Pharma 20,000 DAK 2018 1803041 01/03/2021 57.00 1,140,000.00
67 Propylthiouracil 100 mg Tablet PT. OGB Dexa 23,300 DAK 2018 49G0625 01/06/2022 453.00 10,554,900.00
68 Pyridoxin HCl 10 mg Tablet PT. Kimia Farma 191,700 DAK 2016 E160465B 01/05/2019 124.00 23,770,800.00
69 Quinine Sulphate 200 mg (Kina) Tablet PT. Kimia Farma 15,900 DAK 2016 E150827B 01/05/2020 704.00 11,193,600.00
70 Ranitidine 150 mg Tablet PT. Holi Pharma 15,500 DAK 2018 1802087 01/02/2020 110.00 1,705,000.00
Ranitidine 150 mg Tablet PT. Hexapharm Jaya 19,000 DAK 2017 HTRNTA72037 01/04/2020 105.00 1,995,000.00
71 Risperidone 1 mg Tablet PT. OGB Dexa 9,700 DAK 2018 49F0242 01/06/2021 228.00 2,211,600.00
72 Risperidone 2 mg Tablet PT. OGB Dexa 13,100 DAK 2018 49A0045 01/12/2020 273.00 3,576,300.00
73 Risperidone 3 mg Tablet PT. Guardian Pharmatama 11,400 DAK 2017 1705081 01/05/2019 539.00 6,144,600.00
74 Retinol 100.000 IU (Biru) Kapsul Lunak PT. Kimia Farma 18,000 DAK 2016 066220W 01/06/2019 298.00 5,364,000.00
75 Salbutamol 2 mg Tablet PT. Graha Farma 26,400 DAK 2108 XJ248G 01/10/2021 64.00 1,689,600.00
76 Salbutamol 4 mg Tablet PT. Kimia Farma 71,700 DAK 2016 G160925B 01/07/2021 84.00 6,022,800.00
Salbutamol 4 mg Tablet PT. Graha Farma 100,000 DAK 2018 YC313G 01/03/2022 74.00 7,400,000.00
77 Simvastatin 10 mg Tablet PT. Yarindo Farmatama 17,100 DAK 2018 A8729DV 01/04/2020 110.00 1,881,000.00
78 Simvastatin 20 mg Tablet PT. Kimia Farma 178,000 DAK 2016 H160958B 01/08/2019 252.00 44,856,000.00
Simvastatin 20 mg Tablet PT. Tempo Scan Pasific 5,000 DAK 2018 022678 01/02/2020 214.00 1,070,000.00
79 Tablet Tambah Darah (30's) Tablet PT. Phapros 97,440 DAK 2017 06818063 01/03/2019 375.00 36,540,000.00
Tablet Tambah Darah (30's) Tablet PT. Phapros 84,210 DAK 2017 06818074 01/04/2019 375.00 31,578,750.00
80 Theophyllin 150 mg (Bronsolvan) Tablet PT. Kalbe Farma 5,500 DAK 2016 KTBSVC63486 01/06/2021 285.01 1,567,555.00
Page 6 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Theophyllin 150 mg (Bronsolvan) Tablet PT. Kalbe Farma 8,000 DAK 2016 KTBSYC63456 01/09/2021 285.01 2,280,080.00
81 Thiamin HCl (Vitamin B1) 50 mg Tablet PT. Novapharin 80,000 DAK 2018 1808-15-158 01/06/2022 85.00 6,800,000.00
82 Vitamin B Kompleks Tablet PT. Kimia Farma 355,800 DAK 2018 B80419T 01/02/2021 123.00 43,763,400.00
Vitamin B Kompleks Tablet PT. Kimia Farma 37,600 DAK 2018 C80432T 01/03/2021 123.00 4,624,800.00
83 Zinc 20 mg Tablet PT. Indofarma 600 DAK 2017 1611040 01/12/2019 540.00 324,000.00
Zinc 20 mg Tablet PT. Kimia Farma 9,000 DAK 2017 D70890J 01/04/2019 540.00 4,860,000.00
Zinc 20 mg Tablet PT. Kimia Farma 10,600 DAK 2017 C70601J 01/03/2019 540.00 5,724,000.00
Zinc 20 mg Tablet PT. Kimia Farma 200,000 DAK 2018 G82019J 01/07/2020 551.00 110,200,000.00
Sirup, Suspensi dan Drop 268,873,462.00

1 Amoxicillin Syr 125 mg/5ml Botol PT. Mersi Farma 11,400 DAK 2018 270568 01/12/2019 4,999.60 56,995,440.00
Amoxicillin Syr 125 mg/5ml Botol PT. Novapharin 126 DAK 2018 1807-04-96 01/07/2020 4,999.60 629,949.60
Amoxicillin Syr 125 mg/5ml Botol PT. Novapharin 5,794 DAK 2018 1808-04-96 01/08/2020 4,999.60 28,967,682.40
2 Antasida DOEN Suspensi Botol PT. Lucas 11,850 DAK 2018 18SG331 01/07/2020 2,051.00 24,304,350.00
3 Chloramphenicol Suspensi 125 mg/ml Botol PT. Novapharin 2,958 DAK 2015 1506-01-82A 01/06/2019 7,080.00 20,942,640.00
4 Cotrimoxazol Suspensi 240 mg/5ml Botol PT. Mersifarma Tirmaku Mercusana 7,400 DAK 2018 A80996 01/05/2020 2,052.00 15,184,800.00
5 Domperidon Suspensi 5 mg/ml Botol PT. Novapharin 2,100 DAK 2018 1806-11-186 01/06/2020 2,781.00 5,840,100.00
6 Metronidazol Suspensi 125 mg/5ml Botol PT. Meprofarm 80 DAK 2018 E7H422 01/08/2019 3,950.00 316,000.00
7 Paracetamol Sirup 120 mg/5ml Botol PT. Novapharin 27,300 DAK 2018 1808-31-86 01/08/2022 3,850.00 105,105,000.00
Paracetamol Sirup 120 mg/5ml Botol PT. Novapharin 2,750 DAK 2018 1809-28-86 01/09/2022 3,850.00 10,587,500.00

1 Aminophyline Injeksi Ampul PT. Phapros 120 DAK 2016 95307039-1 01/08/2019 3,349.00 401,880.00
Aminophyline Injeksi Ampul PT. Phapros 990 DAK 2017 063070051 01/05/2020 2,998.00 2,968,020.00
2 Ampicillin Injeksi 1000 mg Vial PT. Phapros 920 DAK 2018 16426026 01/06/2020 8,649.00 7,957,080.00
3 Aqua DM 1000 ml Botol 303 DAK 2017 AQUADM2017 31/12/2030 11,000.00 3,333,000.00
4 Aqua Pro Injeksi Ampul PT. Otsuka 7,844 DAK 2016 00H46A 31/08/2019 2,750.00 21,571,000.00
5 Calcium Gluconat Inj 100 mg/ml Ampul PT. Ethica Industri 456 DAK 2017 97LC0107 01/03/2021 9,955.00 4,539,480.00
6 Chlorpromazin Injeksi 5 mg/ml Ampul PT. Phapros 150 DAK 2018 95330003 31/08/2019 1,585.00 237,750.00
8 Combivent Ampul PT. Boehringer 4,120 DAK 2018 7984013 31/11/2019 4,550.00 18,746,000.00
9 Dexamethasone Injeksi Ampul PT. Meprofarm 300 DAK 2018 30846 01/02/2020 1,152.00 345,600.00
Dexamethasone Injeksi Ampul PT. Phapros 8,600 DAK 2017 06337041BF 01/03/2020 1,605.00 13,803,000.00
10 Diazepam Injeksi 5 mg/ml Ampul PT. Indofarma 1,095 DAK 2018 F8B244 01/02/2020 4,389.00 4,805,955.00
11 Diphenhydramine HCl Inj 10 mg/ml Ampul PT. Lucas Djaja 2,310 DAK 2018 18IB001 01/02/2021 1,152.00 2,661,120.00
12 Ephinefrin Injeksi 1 mg/ml Ampul PT. Ethica Industri 550 DAK 2018 97LI0122 01/09/2020 1,408.00 774,400.00
13 Furosemide Injeksi 10 mg/ml Ampul PT. Indofarma 125 DAK 2017 IL17A004 01/02/2019 2,700.00 337,500.00
14 Gentamycin Sulphate Injeks i40 mg/ml Ampul PT. Indofarma 135 DAK 2017 BF16J152 01/11/2019 3,556.00 480,060.00
15 Haloperidol Dekanoat Inj 50 mg/ml Ampul PT. Soho Industri Pharmasi 15 DAK 2018 582T 01/05/2021 101,300.00 1,519,500.00
16 Lidocain Compositum Injeksi Ampul PT. Phapros 5,037 DAK 2018 16815003-2 31/01/2021 1,205.00 6,069,585.00
Lidocain Compositum Injeksi Ampul PT. Lucas Djaja 3,330 DAK 2016 17ID041 01/04/2021 1,937.00 6,450,210.00
Lidocain Compositum Injeksi Ampul PT. Lucas Djaja 1,200 DAK 2016 17IE018 01/05/2021 1,937.00 2,324,400.00
17 Methyl Ergometrin Inj 0,2 mg/ml Ampul PT. Ethica Industri 135 DAK 2017 97KL0047 01/12/2019 2,992.00 403,920.00
Methyl Ergometrin Inj 0,2 mg/ml Ampul PT. Ethica Industri 300 DAK 2018 97LH0031 01/08/2020 3,102.00 930,600.00
18 Omeprazole Inj 40 mg/ml Ampul PT. Otto Pharmaceutical 2,334 DAK 2017 7D0321 01/04/2019 17,657.00 41,211,438.00
Page 7 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Omeprazole Inj 40 mg/ml Ampul PT. Anugrah Argon Medica 6,450 DAK 2017 2480763 01/02/2020 12,998.00 83,837,100.00
19 Oxytocin Injeksi 10 IU/ml Ampul PT. Ethica Industri 4,800 DAK 2016 97KD0023 01/04/2019 1,900.00 9,120,000.00
Oxytocin Injeksi 10 IU/ml Ampul PT. Ethica Industri 1,500 DAK 2018 968E0062A 01/05/2020 1,199.00 1,798,500.00
Oxytocin Injeksi 10 IU/ml Ampul PT. Ethica Industri 4,800 DAK 2018 97LK0057 01/10/2020 1,199.00 5,755,200.00
20 Phenobarbital Injeksi 50 mg/ml Ampul PT. Rajawali Nusindo 20 DAK 2018 95803003-2 01/08/2020 1,950.00 39,000.00
21 Phytomenadion Inj 2 mg/ml Ampul PT. Phapros 630 DAK 2018 06478065 01/11/2019 3,867.00 2,436,210.00
22 Prokain Benzil Penisilin Injeksi 3.000.000 UI Vial PT. Phapros 45 DAK 2016 95387007 01/07/2020 9,046.00 407,070.00

1 Acyclovir 5% Salep Kulit Tube PT. Indofarma 350 DAK 2017 1708072 01/08/2021 3,600.00 1,260,000.00
2 Antibakteri, kombinasi : basitrasin 500 UI/g+ Polimiksin Tube PT. Indofarma 1,000 DAK 2017 1706003 01/06/2021 3,071.00 3,071,000.00
Antibakteri, kombinasi : basitrasin 500 UI/g+ Polimiksin Tube PT. Indofarma 5,625 DAK 2017 1707006 01/07/2021 3,071.00 17,274,375.00
3 Antifungi Pot PT. Marin 96 DAK 2016 165F126A 01/06/2020 4,366.00 419,136.00
Antifungi Pot PT. Indofarma 360 DAK 2018 18SD001A 01/04/2022 4,721.00 1,699,560.00
4 Bedak Salicyl 2% Bungkus PT. Rama Mulia 1,668 DAK 2016 A80JFX0280 01/10/2019 1,046.00 1,744,728.00
5 Betamethasone cream Tube PT. Kimia Farma 6,950 DAK 2018 E81079T 01/05/2021 1,373.00 9,542,350.00
6 Chloramphenicol 1% Salep Mata Tube PT. Kimia Farma 4,368 DAK 2018 E81577W 01/05/2021 1,925.00 8,408,400.00
7 Chloramphenicol 2% Salep Kulit (Bufacetin) Tube PT. Bufa Aneka 2,918 DAK 2017 I0205715 01/05/2020 3,223.00 9,404,714.00
Chloramphenicol 2% Salep Kulit (Bufacetin) Tube PT. Bufa Aneka 1,000 DAK 2018 I0208801 01/08/2021 3,171.00 3,171,000.00
8 Chloramphenicol Tetes Telinga (Erlamycetin) Botol PT. Erella 673 DAK 2018 D0653031 01/01/2020 8,000.00 5,384,000.00
Chloramphenicol Tetes Telinga (Erlamycetin) Botol PT. Erella 1,064 DAK 2018 D0653034 01/07/2021 8,000.00 8,512,000.00
9 Hydrocortison 2,5% cream Tube PT. Kimia Farma 264 DAK 2015 IG1227T 01/08/2020 2,868.00 757,152.00
Hydrocortison 2,5% cream Tube PT. Kimia Farma 4,800 DAK 2018 E81177T 01/05/2022 2,533.00 12,158,400.00
10 Ketoconazole Cream 2% Tube PT. Kimia Farma 250 DAK 2018 H71260T 01/08/2021 2,577.00 644,250.00
11 Miconazole 2% Tube PT. Kimia Farma 3,096 DAK 2015 085024W 01/08/2019 3,075.00 9,520,200.00
12 Oxytetrasiklin Salep Mata 1% Tube PT. Kimia Farma 375 DAK 2018 D81127W 01/04/2021 2,600.00 975,000.00
13 Perak Sulfadiazin krim 1% Tube PT. Darya Varia Laboratoria 609 DAK 2017 159LM 01/09/2020 20,700.00 12,606,300.00
14 Permetrin 10 g (Scabimite) Tube PT. Galenium Pharmasia 810 DAK 2016 C083I1505 01/09/2020 12,155.00 9,845,550.00
15 Salep-24 Pot PT. Holi Pharma 1,533 DAK 2018 4803032 01/03/2022 2,750.00 4,215,750.00
Suppositoria dan Larutan Rektal 4,417,350.00

1 Antihemoroid Suppo Supp PT. Kimia Farma 1,130 DAK 2018 I72227W 01/09/2021 3,325.00 3,757,250.00
2 Diazepam Lar. Rektal 5 mg/2,5 ml (Stesolid) Ampul PT. Mensa Bina Sukses 50 DAK 2018 V23681703 31/05/2020 13,202.00 660,100.00
Antiseptik dan Desinfektan 121,240,205.00

1 Alcohol 70% Botol PT. Jayamas Medica Industri 502 DAK 2017 22091788 01/08/2021 28,750.00 14,432,500.00
2 Alcohol Swab Pcs PT. Jayamas Medica Industri 2,200 DAK 2016 02051688 01/04/2019 110.00 242,000.00
Alcohol Swab Pcs PT. Jayamas Medica Industri 68,600 DAK 2016 18071688 01/06/2019 110.00 7,546,000.00
3 Antiseptik Kumur Botol PT. Mahakam Beta Farma 817 DAK 2018 DB81024 01/03/2021 11,550.00 9,436,350.00
4 Etakridin (Rivanol) Botol PT. Jayamas Medica Industri 363 DAK 2018 10011788 01/12/2019 3,450.00 1,252,350.00
5 Hand Rub (E Care Cairan Antiseptik 500 ml) Botol PT. Tri Sapta Jaya 78 DAK 2018 180109E 01/01/2021 63,840.00 4,979,520.00
6 Hand Wash (E Care Sabun Cair 500 ml) Botol PT. Tri Sapta Jaya 125 DAK 2018 PP170502 30/05/2020 70,917.00 8,864,625.00
7 Lysol Botol PT. Jayamas Medica Industri 3 DAK 2018 22111788 01/10/2020 47,150.00 141,450.00
Lysol Botol PT. Jayamas Medica Industri 120 DAK 2018 04121788 01/11/2020 47,150.00 5,658,000.00
8 Povidon Iodium 10% 30 ml Botol PT. Jayamas Medica Industri 668 DAK 2016 25071688 01/06/2019 3,190.00 2,130,920.00
Page 8 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Povidon Iodium 10% 30 ml Botol PT. Jayamas Medica Industri 1,691 DAK 2016 02081688 01/07/2019 3,190.00 5,394,290.00
9 Povidon Iodium 10% 300 ml Botol PT. Jayamas Medica Industri 2,907 DAK 2016 21071688 01/06/2019 19,800.00 57,558,600.00
Povidon Iodium 10% 300 ml Botol PT. Jayamas Medica Industri 48 DAK 2016 19051788 01/04/2020 19,800.00 950,400.00
Povidon Iodium 10% 300 ml Botol PT. Jayamas Medica Industri 134 DAK 2016 28071788 01/06/2020 19,800.00 2,653,200.00
Larutan Elektrolit dan Cairan Infus 338,224,885.00

1 Glucosa 5% (D5%) Botol PT. Widatra Bhakti 3,040 DAK 2017 270319 01/02/2020 6,970.00 21,188,800.00
Glucosa 5% (D5%) Botol PT. Widatra Bhakti 4,980 DAK 2018 270609 01/05/2020 6,900.00 34,362,000.00
2 Glucosa 10% (D10%) Botol PT. Widatra Bhakti 180 DAK 2017 261223 01/11/2019 7,500.00 1,350,000.00
Glucosa 10% (D10%) Botol PT. Widatra Bhakti 500 DAK 2018 271106 01/10/2020 7,500.00 3,750,000.00
3 Natrium Chlorida (NaCl) 0,9% Botol PT. Widatra Bhakti 4,540 DAK 2017 470505 17/04/2019 6,410.00 29,101,400.00
Natrium Chlorida (NaCl) 0,9% Botol PT. Widatra Bhakti 7,960 DAK 2018 280102 01/12/2022 6,410.00 51,023,600.00
4 Ringer Asetat (Asering) Botol PT. Otsuka 2,375 DAK 2017 47D77A 08/04/2020 9,275.00 22,028,125.00
5 Ringer Asetat (Widabes) Botol PT. Widatra Bhakti 1,760 DAK 2018 280201 01/01/2020 9,646.00 16,976,960.00
6 Ringer Laktat Botol PT. Widatra Bhakti 5,040 DAK 2017 471101 01/10/2021 7,150.00 36,036,000.00
Ringer Laktat Botol PT. Widatra Bhakti 17,120 DAK 2018 370514 01/04/2022 7,150.00 122,408,000.00
Vaksin dan Serum 59,975,373.90

1 Anti Tetanus Serum (Tetagam P. Prefiled Syringe 1 ml) Ampul PT. Dexa Medica 10 DAK 2017 35245831J 01/02/2020 169,999.99 1,699,999.90
Anti Tetanus Serum (Tetagam P. Prefiled Syringe 1 ml) Ampul PT. Dexa Medica 88 DAK 2018 35845821B 01/08/2020 176,800.00 15,558,400.00
2 Serum Anti Bisa Ular (ABU) Vial PT. Biofarma 89 DAK 2018 4700718 01/05/2020 479,966.00 42,716,974.00
Preparat Gigi 49,037,000.00

1 Devitalisasi Pasta non Arsen (Devitec) / Pulp-X Set Prevest Den Pro Limited 12 DAK 2017 1881606 01/05/2019 375,000.00 4,500,000.00
2 Ethyl Chloride Kaleng PT. Germany 93 DAK 2017 160921 01/09/2019 129,000.00 11,997,000.00
3 Fletcher Kotak 8 DAK 2017 1311733 01/03/2020 150,000.00 1,200,000.00
4 Fuji GC IX Besar Set GC Corporation, Japan 3 DAK 2017 1610051 01/10/2019 980,000.00 2,940,000.00
5 Glass ionomer Kotak 11 DAK 2017 1607221 21/07/2019 750,000.00 8,250,000.00
6 Iodoform Pasta/Iodotin Pcs Tehno Dent Co. LTD, Russia 4 DAK 2017 05 01/03/2020 200,000.00 800,000.00
7 Komposit Tube 3M ESPE Dental Products, USA 10 DAK 2017 N865771 01/10/2020 700,000.00 7,000,000.00
8 Spongestan (Hemospon) Kotak 55 DAK 2017 17001 01/02/2020 200,000.00 11,000,000.00
9 Tri Kresol Formalin (TKF) Kotak Bio Dinamica Quimica e-Pharmaceutic 9 DAK 2017 76116 01/11/2019 150,000.00 1,350,000.00
Laboratorium 16,750,231.94
1 Sarung Tangan Steril 7.5 Pair 73 DAK 2016 16075311 01/02/2021 1,007.16 73,522.68
Sarung Tangan Steril 7.5 Pair 100 DAK 2016 15184311 01/06/2020 8,284.00 828,400.00
2 Aquadest Botol 1 Liter 35 DAK 2016 - - 17,000.00 595,000.00
3 Pot Sputum Non Steril Pcs 3210 DAK 2014 - - 1,750.00 5,617,500.00
4 Pot Sputum Steril Pcs 200 DAK 2016 - - 7,000.00 1,400,000.00
5 Slide Frosted Kotak 169 DAK 2014 - - 19,500.00 3,295,500.00
6 Box slide Kotak 35 DAK 2014 - - 36,000.00 1,260,000.00
7 Parafilm Kotak 4 DAK 2016 - - 550,000.00 2,200,000.00
8 Urine Gluco Protein Test Kotak 3 DAK 2016 56160357 01/05/2019 11,495.00 34,485.00
9 Benecheck Asam Urat Kotak PT. Mitra Asa Pratama 7 DAK 2018 U18099060 01/12/2019 156,558.44 1,095,909.08
10 Benecheck Glucosa Kotak PT. Mitra Asa Pratama 2 DAK 2018 G18148067 01/06/2020 174,957.59 349,915.18
Page 9 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Bahan Kimia 136,062,500.00

1 Abate Sachet PT. BASF Indonesia 16,750 DAK 2016 1701120002 14/07/2019 3,814.00 63,884,500.00
Abate Sachet PT. BASF Indonesia 5,000 DAK 2018 1701020001 11/01/2019 3,814.00 19,070,000.00
2 Cynoff Botol PT. Bina Guna Kimia 22 DAK 2017 9500223 01/11/2020 1,484,000.00 32,648,000.00
3 Kaporit Galon PT. Rizki Educalab 31 DAK 2017 060417 - 660,000.00 20,460,000.00
Imunisasi 254,103,900.00
1 Alat Suntik Sekali Pakai 0.05 ml Pcs PT. Sotoshot 3400 APBD I PROPINSI 2016 1501406 01/12/2019 1,456.00 4,950,400.00
Alat Suntik Sekali Pakai 0.05 ml Pcs PT. Medeco 3900 APBN PUSAT 2018 3814/13 01/08/2019 1,456.00 5,678,400.00
Alat Suntik Sekali Pakai 0.05 ml Pcs PT. One Jet 4200 APBD I PROPINSI 2018 18001 01/01/2023 1,456.00 6,115,200.00
Alat Suntik Sekali Pakai 0.05 ml Pcs PT. One Jet 4800 APBN 2018 18003 01/07/2023 1,456.00 6,988,800.00
Alat Suntik Sekali Pakai 0.05 ml Pcs PT. Skifa Ananta Dharma 4000 DAK 2018 1707401 01/02/2022 1,456.00 5,824,000.00
Alat Suntik Sekali Pakai 0.05 ml Pcs PT. One Jet 2400 APBN PUSAT 2017 16004 01/01/2023 1,456.00 3,494,400.00
2 Alat Suntik Sekali Pakai 0.5 ml Pcs PT. One Jet 3200 APBN PUSAT 2017 17119 01/05/2022 1,877.00 6,006,400.00
Alat Suntik Sekali Pakai 0.5 ml Pcs PT. Skifa Ananta Dharma 11400 PROGRAM MR 1804407 01/03/2023 1,877.00 21,397,800.00
Alat Suntik Sekali Pakai 0.5 ml Pcs PT. Skifa Ananta Dharma 9600 PUSAT 2018 1808409 01/03/2023 1,877.00 18,019,200.00
Alat Suntik Sekali Pakai 0.5 ml Pcs PT. Skifa Ananta Dharma 4800 GAVI 2018 1808409 01/03/2023 1,877.00 9,009,600.00
3 Alat Suntik Sekali Pakai 5 ml Pcs PT. One Jet 1800 APBD I PROPINSI 2018 165021 01/04/2021 1,685.00 3,033,000.00
Alat Suntik Sekali Pakai 5 ml Pcs PT. Skifa Ananta Dharma 4000 DAK 2018 1707401 01/02/2022 1,685.00 6,740,000.00
Alat Suntik Sekali Pakai 5 ml Pcs PT. One Jet 600 PROGRAM MR 165021 01/04/2021 1,685.00 1,011,000.00
Alat Suntik Sekali Pakai 5 ml Pcs PT. Skifa Ananta Dharma 2700 APBN 2018 1804401 01/03/2023 1,685.00 4,549,500.00
Lain-Lain
Dana Kapitasi BPJS 350,000.00
1 Formalin Botol - 7 Lain-Lain 2014 - 01/01/2025 50,000.00 350,000.00
Relokasi Dari Dana JKN Puskesmas 0.00

1 OBH Sirup Botol PT. Erella 35 RELOKASI18 2550023 01/02/2019 0.00 0.00
2 Thiamin HCl (Vitamin B1) 50 mg Tablet PT. Sejahtera Lestari Farma 14,000 RELOKASI18 53509 01/08/2019 0.00 0.00
3 Trihexiphenidil HCl 2 mg (Heximer) Tablet PT. Mersifarma 26,000 RELOKASI18 150315 01/05/2019 0.00 0.00
Page 10 of 54
TANGGAL HARGA
KADALUARSA SATUAN
DANA APBN 908,651,212.00

Obat - Obatan 461,869,642.00

7 Ibuprofen 400 mg Tablet PT. Phyto Kemo Agung 10,000 APBD I 2017 BB911927 01/02/2021 130.00 1,300,000.00
OAT Kat. Anak Tahap Intensif Paket Depkes 6 APBN 2018 16490328 01/06/2020 232,518.00 1,395,108.00
Page 11 of 54
TANGGAL HARGA
KADALUARSA SATUAN


DANA DAK 4,577,265,287.94

Page 12 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Page 13 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Obat - Obatan 1,939,184,800.00

Page 14 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Page 15 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Page 16 of 54
TANGGAL HARGA
KADALUARSA SATUAN


Page 17 of 54
TANGGAL HARGA
KADALUARSA SATUAN

Page 18 of 54
TANGGAL HARGA
KADALUARSA SATUAN




Page 19 of 54
TANGGAL HARGA
KADALUARSA SATUAN

2 Aqua DM 1000 ml Botol 35 DAK 2016 - - 11,000.00 385,000.00
Bahan Kimia 136,062,500.00

Imunisasi 252,277,900.00
Page 20 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Lain-Lain
1 Formalin Botol - 7 Lain-Lain 2014 - 50,000.00 350,000.00
Relokasi Dari Dana JKN Puskesmas 2,325,750.00

1 OBH Sirup Botol PT. Erella 35 RELOKASI18 2550023 01/02/2019 1,250.00 43,750.00
2 Thiamin HCl (Vitamin B1) 50 mg Tablet PT. Sejahtera Lestari Farma 14,000 RELOKASI18 53509 01/08/2019 85.00 1,190,000.00
3 Trihexiphenidil HCl 2 mg (Heximer) Tablet PT. Mersifarma 26,000 RELOKASI18 150315 01/05/2019 42.00 1,092,000.00
REVISI TERAKHIR 9 MEI 2019 PUKUL 15.00 WIT
Page 21 of 54
TANGGAL HARGA
KADALUARSA SATUAN
DANA APBN 908,651,212.00

Obat - Obatan 461,869,642.00

7 Ibuprofen 400 mg Tablet PT. Phyto Kemo Agung 10,000 APBD I 2017 BB911927 01/02/2021 130.00 1,300,000.00
OAT Kat. Anak Tahap Intensif Paket Depkes 6 APBN 2018 16490328 01/06/2020 232,518.00 1,395,108.00
Page 22 of 54
TANGGAL HARGA
KADALUARSA SATUAN


DANA DAK 4,577,265,287.94

Page 23 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Page 24 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Obat - Obatan 1,939,184,800.00

Page 25 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Page 26 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Page 27 of 54
TANGGAL HARGA
KADALUARSA SATUAN


Page 28 of 54
TANGGAL HARGA
KADALUARSA SATUAN

Page 29 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Page 30 of 54
TANGGAL HARGA
KADALUARSA SATUAN




Page 31 of 54
TANGGAL HARGA
KADALUARSA SATUAN
2 Aqua DM 1000 ml Botol 35 DAK 2016 - - 11,000.00 385,000.00
Bahan Kimia 136,062,500.00

Imunisasi 252,277,900.00
Page 32 of 54
TANGGAL HARGA
KADALUARSA SATUAN
Lain-Lain
1 Formalin Botol - 7 Lain-Lain 2014 - 50,000.00 350,000.00
Relokasi Dari Dana JKN Puskesmas 2,325,750.00

1 OBH Sirup Botol PT. Erella 35 RELOKASI18 2550023 01/02/2019 1,250.00 43,750.00
2 Thiamin HCl (Vitamin B1) 50 mg Tablet PT. Sejahtera Lestari Farma 14,000 RELOKASI18 53509 01/08/2019 85.00 1,190,000.00
3 Trihexiphenidil HCl 2 mg (Heximer) Tablet PT. Mersifarma 26,000 RELOKASI18 150315 01/05/2019 42.00 1,092,000.00
REVISI TERAKHIR 10 MEI 2019 PUKUL 11.02 WIT
Page 33 of 54
E-LOGISTIK PRODUSEN TANGGAL HARGA

NO NAMA OBAT SATUAN PRODUSEN/MERK JUMLAH SUMBER DANA NO. BATCH KADALUARSA NILAI PERSEDIAAN
NAMA INN E-LOGISTIK SATUAN
APBD I PROV 2016 4,950,400.00
APBD 1 PROV 2018 9,148,200.00
2 Alat Suntik Sekali Pakai 0.05 ml Pcs PT. One Jet 4200
APBD I PROPINSI 2018 18001 01/01/2023 1,456.00 6,115,200.00
3 Alat Suntik Sekali Pakai 5 ml Pcs PT. One Jet 1800
APBD I PROPINSI 2018 165021 01/04/2021 1,685.00 3,033,000.00
APBN 2014 2,255,000.00
APBN 2016 1,675,500.00
APBN 2017 115,817,480.00
Guilin Pharmaceutical
10 Artesunat Injeksi Vial APBN 2017 LA16518 14/03/2019
Co.,LDT 22 40,900.00 899,800.00
Haloperidol Dekanoat Injection 50
11 Ampul PT. Soho Industri Pharmasi APBN 2017 6009 01/10/2019
mg/ml 30 97,500.00 2,925,000.00
APBN 2018 525,652,368.00
PT. Jayamas Medica
12 Catgut Plain Pcs APBN 2018 615134 01/07/2021
Industri 24 54,166.67 1,300,000.00
13 Hepatitis B Imunoglobin (Hb Ig) Vial Depkes APBN 2018 H2MAB00083 18/08/2020
50 1,300,000.00 65,000,000.00
PT. Jayamas Medica
14 Masker ties on Pcs APBN 2018 08081687 01/12/2020
Industri 2,650 330.00 874,500.00
15 Plester 5 yard x 2 inc (Hansaplast) Rol PT. Beiersctorf Indo APBN 2018 71815448 01/05/2020
50 25,404.00 1,270,200.00
16 Plester 5 yard x 2 inc (Hansaplast) Rol PT. Beiersctorf Indo APBN 2018 72946648 01/07/2020
300 20,332.20 6,099,660.00
18 Albendazole 400 mg Tablet PT. Indofarma APBN 2018 1802014 01/03/2021
52,920 424.00 22,438,080.00
153,090 424.00 64,910,160.00
2,100 424.00 890,400.00
21 Anti Malaria (DHP) Kotak 9's Depkes APBN 2018 170412 01/04/2019
5 31,482.00 157,410.00
22 Anti Malaria (DHP) Kotak 9's Depkes 78 APBN 2018 170503 01/05/2019 31,482.00 2,455,596.00
23 Diazepam 5 mg Tablet PT. Kimia Farma APBN 2018 A80480 01/02/2022
4,200 109.00 457,800.00
24 Garam Oralit Sachet PT. Kimia Farma APBN 2018 G81460B 01/06/2023
200 263.00 52,600.00
25 Garam Oralit Sachet PT. Kimia Farma APBN 2018 H81461B 01/07/2023
1,000 263.00 263,000.00
26 Garam Oralit Sachet PT. Kimia Farma 18,000 APBN 2018 H81466B 01/07/2023 263.00 4,734,000.00
27 Haloperidol Dekanoat Inj 50mg/ml Ampul PT. Soho Industri Pharmasi APBN 2018 6009 01/10/2019
30 97,500.00 2,925,000.00
Page 34 of 54
28 Ibuprofen 400 mg Tablet PT. Phyto Kemo Agung APBN 2018 BB911927 01/02/2021
10,000 130.00 1,300,000.00
30 OAT Kat. Anak Paket Depkes 6 APBN 2018 16490328 01/06/2020 232,518.00 1,395,108.00
32 Piroxicam 20 mg Tablet PT. Triman APBN 2018 D7019 01/04/2020
4,000 98.00 392,000.00
33 Retinol 200.000 IU (Merah) Kapsul Lunak PT. Kimia Farma APBN 2018 086152W 01/08/2019
220,500 531.00 117,085,500.00
34 Retinol 200.000 IU (Merah) Kapsul Lunak PT. Kimia Farma APBN 2018 H71975W 01/08/2020
188,000 531.00 99,828,000.00
36 Oxytetrasiklin Salep Mata 0,1% Tube PT. Kimia Farma APBN 2018 18242026W 01/09/2021
1,200 2,600.00 3,120,000.00
37 Alat Suntik Sekali Pakai 0.05 ml Pcs PT. One Jet 4800 APBN 2018 18003 01/07/2023 1,456.00 6,988,800.00
40 Alat Suntik Sekali Pakai 0.5 ml Pcs PT. One Jet APBN 2018 18137 1,877.00 9,009,600.00
4800 01/06/2023
41 Alat Suntik Sekali Pakai 0.5 ml Pcs PT. One Jet APBN 2018 18134 1,877.00 6,006,400.00
3200 01/06/2023
43 Alat Suntik Sekali Pakai 5 ml Pcs PT. Skifa Ananta Dharma 2700 APBN 2018 1804401 01/03/2023 1,685.00 4,549,500.00
44 Tablet Tambah Darah Tablet PT. Phapros 810 APBN 2018 06818076 4/1/2019 375.00 303,750.00
APBN PUSAT 2017 112,407,800.00
48 Alat Suntik Sekali Pakai 0.5 ml Pcs PT. One Jet APBN PUSAT 2017 16126 1,877.00 3,003,200.00
1600 01/07/2021
49 Alat Suntik Sekali Pakai 0.5 ml Pcs PT. One Jet 26200
APBN PUSAT 2017 15110 01/04/2020 1,877.00 49,177,400.00
APBN PUSAT 2018
51 Alat Suntik Sekali Pakai 0.05 ml Pcs PT. Medeco 3900 APBN PUSAT 2018 3814/13 01/08/2019 1,456.00 5,678,400.00
DAK 2014 10,173,000.00
52 Pot Sputum Non Steril Pcs
3210 DAK 2014 - - 1,750.00 5,617,500.00
53 Slide Frosted Kotak
169 DAK 2014 - - 19,500.00 3,295,500.00
DAK 2015 44,512,542.00
PT. Terumo Medical
55 Stomach tube no. 12 Pcs
Product 28 DAK 2015 140224B 01/01/2019 9,099.00 254,772.00
PT. Terumo Medical
56 Stomach tube no. 18 Pcs
Product 22 DAK 2015 140923B 01/08/2019 9,099.00 200,178.00
60 Metronidazole 500 mg Tablet PT. Phyto Kemo Agung 300 DAK 2015 ZI912610 01/10/2019 164.00 49,200.00
Page 35 of 54
Chloramphenicol Suspensi 125
61 Botol PT. Novapharin DAK 2015 1506-01-82A 01/06/2019
mg/ml 2,958 7,080.00 20,942,640.00
62 Hydrocortison 2,5% cream Tube PT. Kimia Farma DAK 2015 IG1227T 01/08/2020
264 2,868.00 757,152.00
63 Miconazole 2% Tube PT. Kimia Farma DAK 2015 085024W 01/08/2019
3,096 3,075.00 9,520,200.00
DAK 2016 897,928,076.58
64 Alat Suntik sekali pakai 5 ml Pcs Aximed - Shanghai Kindly 5,600 DAK 2016 20150830 01/07/2020
1,011.52 5,664,512.00
65 Alat Suntik sekali pakai 5 ml Pcs Aximed - Shanghai Kindly 500 DAK 2016 20170615 01/05/2022
1,011.52 505,760.00
1,419.18 567,672.00
67 Alat Suntik sekali pakai 20 ml Pcs Aximed - Shanghai Kindly 2,200 DAK 2016 20150425 01/03/2020
2,129.86 4,685,692.00
69 Cathejell® Lidocain Pcs Pharm Fabrik Montavit Get 25 DAK 2016 11801 01/05/2021
44,100.00 1,102,500.00
70 Cathejell® Lidocain Pcs Pharm Fabrik Montavit Get 5 DAK 2016 11771 01/03/2021 44,100.00 220,500.00
71 IV Catheter no. 16 Pcs PT. Otsuka

200 DAK 2016 30036 01/03/2021 8,470.00 1,694,000.00
PT. Jayamas Medica
72 Kassa Hidrofil Steril 16x16 cm Kotak
Industri 1,260 DAK 2016 19101588 01/09/2020 6,380.00 8,038,800.00
73 Masker N95/R10 Pcs Kimberly Clark China
920 DAK 2016 MASKERN95 01/12/2030 21,450.00 19,734,000.00
Stardec - WL Medical co.
74 Nasal Canula Anak Pcs
Ltd 25 DAK 2016 1511021916 01/10/2020 10,000.00 250,000.00
Stardec - WL Medical co.
75 Nasal Canula Dewasa Pcs
Ltd 2 DAK 2016 1605020768 01/04/2021 10,000.00 20,000.00
76 Plester Pharmafix Pcs Pharmaplast Amaria Egypt
737 DAK 2016 10B16 01/02/2021 29,700.00 21,888,900.00
Aximed - Zhejiang Kindly
77 Sarung Tangan Non Steril L Pcs
Medical
6,100 DAK 2016 1603033 24/01/2021 1,007.16 6,143,676.00
78 Sarung Tangan Non Steril M Pcs
Medical
39,800 DAK 2016 1603012 09/02/2021 1,007.16 40,084,968.00

79 Sarung Tangan Steril no. 7 Pcs
Medical
6,950 DAK 2016 16160311 01/05/2021 8,284.00 57,573,800.00
80 Sarung Tangan Steril no. 7,5 Pcs
Medical
6,600 DAK 2016 16160311 01/05/2021 8,284.00 54,674,400.00
PT. Jayamas Medica
81 Scalvin no. 25 (Wing Needle) Pcs
Industri 151 DAK 2016 25072014 01/06/2019 1,540.00 232,540.00
Silk Rol (Silk Black Braided 3/0 2
82 Rol Bio Dinamics Germany 31 DAK 2016 003161 01/12/2019 409,065.30 12,681,024.30
metric 100 m)
83 Acyclovir 400 mg Tablet PT. Indofarma DAK 2016 1606044 01/07/2020
123,400 366.00 45,164,400.00
84 Asetosal 80 mg (Miniaspi) Tablet PT. Mersifarma DAK 2016 160315 01/04/2020
11,500 155.00 1,782,500.00
85 Attapulgit 600 mg (Pularex) Tablet PT. Zenith Pharmaceuticals DAK 2016 12204606 01/04/2020
71,400 210.00 14,994,000.00
86 Attapulgit 600 mg (Pularex) Tablet PT. Zenith Pharmaceuticals DAK 2016 7G355318 01/07/2022
10,000 210.00 2,100,000.00
Page 36 of 54
Chloramphenicol 500 mg
88 Kapsul PT. Actavis DAK 2016 T2388140 01/07/2019
(Chloramex) 48,900 1,056.00 51,638,400.00
Chlorpheniramin Maleat (CTM) 4
89 Tablet PT. Trifa Raya Laboratories DAK 2016 1608144 01/08/2021
mg 166,400 53.00 8,819,200.00
90 Ciprofloxacin 500 mg Tablet PT. Novapharin DAK 2016 1607-62-108 01/07/2020
59,700 289.00 17,253,300.00
PT. Rama Emerald Multi
91 Cotrimoxazol 480 mg Tablet DAK 2016 T3107AF 01/08/2019
Sukses 362,600 154.00 55,840,400.00
Page 37 of 54
92 Digoxin 0,25 mg Tablet PT. Yarindo Farma DAK 2016 A7805BT 01/02/2020
300 106.00 31,800.00
94 Domperidon 10 mg Tablet PT. Novapharin 103,500 DAK 2016 1604-09-149 01/04/2020 170.00 17,595,000.00
99 Isosorbide Dinitrate 5 mg Tablet PT. Indofarma DAK 2016 1603006 01/04/2020
500 93.00 46,500.00
102 Phytomenadion 10 mg Tablet PT. Phapros DAK 2016 16381002 01/03/2021
14,000 747.00 10,458,000.00
105 Quinine Sulphate 200 mg (Kina) Tablet PT. Kimia Farma DAK 2016 E150827B 01/05/2020
15,900 704.00 11,193,600.00
106 Retinol 100.000 IU (Biru) Kapsul Lunak PT. Kimia Farma DAK 2016 066220W 01/06/2019
18,000 298.00 5,364,000.00
KTBSVC6348
109 Theophyllin 150 mg (Bronsolvan) Tablet PT. Kalbe Farma 5,500 DAK 2016 01/06/2021 285.01 1,567,555.00
6
KTBSYC6345
110 Theophyllin 150 mg (Bronsolvan) Tablet PT. Kalbe Farma 8,000 DAK 2016 01/09/2021 285.01 2,280,080.00
6
113 Lidocain Compositum Injeksi Ampul PT. Lucas Djaja DAK 2016
3,330 17ID041 01/04/2021 1,937.00 6,450,210.00
114 Lidocain Compositum Injeksi Ampul PT. Lucas Djaja DAK 2016
1,200 17IE018 01/05/2021 1,937.00 2,324,400.00
Prokain Benzil Penisilin Injeksi
116 Vial PT. Phapros DAK 2016
3.000.000 UI 45 95387007 01/07/2020 9,046.00 407,070.00
117 Antifungi Pot PT. Marin DAK 2016 165F126A 01/06/2020
96 4,366.00 419,136.00
118 Bedak Salicyl 2% Bungkus PT. Rama Mulia DAK 2016 A80JFX0280 01/10/2019
1,668 1,046.00 1,744,728.00
119 Permetrin 10 g (Scabimite) Tube PT. Galenium Pharmasia DAK 2016 C083I1505 01/09/2020
810 12,155.00 9,845,550.00
PT. Jayamas Medica
120 Alcohol Swab Pcs DAK 2016 02051688 01/04/2019
Industri
2,200 110.00 242,000.00
PT. Jayamas Medica

121 Alcohol Swab Pcs DAK 2016 18071688 01/06/2019
Industri
68,600 110.00 7,546,000.00
PT. Jayamas Medica
122 Povidon Iodium 10% 30 ml Botol DAK 2016 25071688 01/06/2019
Industri
668 3,190.00 2,130,920.00
PT. Jayamas Medica
Industri
1,691 3,190.00 5,394,290.00
Page 38 of 54
PT. Jayamas Medica

Industri
2,907 19,800.00 57,558,600.00
PT. Jayamas Medica
Industri
48 19,800.00 950,400.00
Page 39 of 54
PT. Jayamas Medica
Industri
134 19,800.00 2,653,200.00
127 Sarung Tangan Steril 7.5 Pair 01/02/2021
73 DAK 2016 16075311 1,007.16 73,522.68
128 Sarung Tangan Steril 7.5 Pair 01/06/2020
100 DAK 2016 15184311 8,284.00 828,400.00
129 Aquadest Botol 1 Liter

35 DAK 2016 - - 17,000.00 595,000.00
130 Pot Sputum Steril Pcs
200 DAK 2016 - - 7,000.00 1,400,000.00
131 Parafilm Kotak
4 DAK 2016 - - 550,000.00 2,200,000.00
132 Urine Gluco Protein Test Kotak 01/05/2019
3 DAK 2016 56160357 11,495.00 34,485.00
DAK 2017 1,114,939,545.54
134 Alat Suntik sekali pakai 0,5 ml Pcs Abu Dhabi Medical Devices 5,900 DAK 2017 031738 01/06/2022
1,877.00 11,074,300.00
1,200.00 240,000.00
136 Blood Transfusion Set Pcs PT. Anugrah Mitra Selaras 444 DAK 2017 01041688 01/02/2022
5,880.00 2,610,720.00
PT. Jayamas Medica
137 Catgut Plain Pcs 168 DAK 2017 1709215 01/09/2022
Industri
6,141.67 1,031,800.56
138 Foley Catheter no. 18 Pcs PT. Anugrah Mitra Selaras

176 DAK 2017 1611021814 01/10/2021 11,040.00 1,943,040.00
139 IV Catheter no. 18 Pcs PT. Anugrah Mitra Selaras

500 DAK 2017 3006217A 01/12/2021 5,040.00 2,520,000.00

3,550 DAK 2017 3326416N 01/11/2021 5,040.00 17,892,000.00

1,060 DAK 2017 3326516N 01/11/2021 7,885.00 8,358,100.00
PT. Jayamas Medica
143 Kapas Pembalut Bungkus
Industri 845 DAK 2017 01091688 01/10/2021 13,750.00 11,618,750.00
144 Sarung Tangan Latex Powder no. S Pcs Multisave Sdn Bhd
1,300 DAK 2017 1000542505 01/10/2019 748.71 973,323.00
145 Sarung Tangan Obgyn Pcs PT. Anugrah Mitra Selaras
640 DAK 2017 17035181 01/01/2022 20,880.00 13,363,200.00
Silk 3/0 (Silk Braided Non PT. Jayamas Medica
146 Pcs 23,508 DAK 2017 1608170 01/08/2021 3,361.11 79,012,973.88
Absorbable Suture Sterile) Industri
PT. Jayamas Medica

147 Under Pad (Soft Pad 60 x 90 cm) Pcs
Industri
12,430 DAK 2017 UNDERPAD17 01/12/2030 4,578.54 56,911,252.20
PT. Jayamas Medica
148 Urine Bag Pcs
Industri 330 DAK 2017 03031788 01/02/2022 3,300.00 1,089,000.00
149 Allopurinol 100 mg Tablet DAK 2017 T11051 AF 01/11/2019
Sukses
32,800 93.00 3,050,400.00
150 Amoxicillin 500 mg Tablet PT. Pharma Laboratories DAK 2017 HJ018430 01/09/2021
343,400 191.00 65,589,400.00
151 Amoxicillin 500 mg Tablet PT. Pharma Laboratories DAK 2017 HK018457 01/10/2021
90,000 191.00 17,190,000.00
152 Asam Ascorbat 250 mg Tablet PT. Tempo Scan Pasific DAK 2017 80027 01/08/2019
5,000 115.00 575,000.00
Page 40 of 54
153 Asam Mefenamat 500 mg Tablet PT. Holi Pharma DAK 2017 1708207 01/08/2020
94,500 219.00 20,695,500.00
154 Asetyl Sistein 200 mg Kapsul PT. Indofarma 60 DAK 2017 1705096 6/1/2019 376.00 22,560.00
155 Captopril 25 mg Tablet PT. Errita Pharma DAK 2017 IH1796 01/03/2021
4,500 154.00 693,000.00
156 Captopril 25 mg Tablet PT. Errita Pharma DAK 2017 JH1911 01/04/2021
210,000 154.00 32,340,000.00
157 Captopril 25 mg Tablet PT. Phapros 5,000 DAK 2017 06324017 01/08/2022 154.00 770,000.00
Page 41 of 54
Chlorpheniramin Maleat (CTM) 4
159 Tablet PT. PIM Pharmaceuticals DAK 2017 09709004 01/09/2020
mg 109,800 60.00 6,588,000.00
PT. Promedrahardjo
160 Dexamethasone 0,5 mg Tablet 176,500 DAK 2017 00717H0320 01/08/2020 43.00 7,589,500.00
Farmasi Industri

161 Erytromycin 500 mg Tablet DAK 2017 T07075AG 01/01/2021
Sukses
22,500 751.00 16,897,500.00
162 Erytromycin 500 mg Tablet DAK 2017 T04038AH 01/10/2021
Sukses
20,000 751.00 15,020,000.00
163 Furosemide 40 mg Tablet PT. Sampharindo Perdana DAK 2017 FE2471 01/05/2021
2,200 81.00 178,200.00
164 Haloperidol 0,5 mg Tablet PT. Holi Pharma 6,000 DAK 2017 1703003 01/03/2020 62.00 372,000.00
165 Haloperidol 0,5 mg Tablet PT. Holi Pharma 2,500 DAK 2017 1707069 01/07/2020 58.00 145,000.00
167 Methyl Prednisolone 4 mg Tablet PT. Molex Ayu DAK 2017 ZS147 01/09/2020
14,500 160.00 2,320,000.00
169 Nifedipin 10 mg Tablet PT. OGB Dexa DAK 2017 48D4190 01/03/2021
9,700 110.00 1,067,000.00
170 Paracetamol 500 mg Tablet PT. PIM Pharmaceuticals DAK 2017 06711023 01/11/2022
100 164.00 16,400.00
171 Propanolol 10 mg Tablet PT. Holi Pharma DAK 2017 1706002 01/06/2019
6,000 66.00 396,000.00
172 Ranitidine 150 mg Tablet PT. Hexapharm Jaya DAK 2017 HTRNTA72037 01/04/2020
19,000 105.00 1,995,000.00
173 Ranitidine 150 mg Tablet PT. Hexapharm Jaya 179,100 DAK 2017 HTRNTA73054 01/05/2020 105.00 18,805,500.00
174 Risperidone 3 mg Tablet PT. Guardian Pharmatama DAK 2017 1705081 01/05/2019
11,400 539.00 6,144,600.00
175 Tablet Tambah Darah (30's) Tablet PT. Phapros DAK 2017 06818063 01/03/2019
97,440 375.00 36,540,000.00
84,210 375.00 31,578,750.00
17,340 375.00 6,502,500.00
277,680 375.00 104,130,000.00
5,670 375.00 2,126,250.00
180 Zinc 20 mg Tablet PT. Indofarma DAK 2017 1611040 01/12/2019
600 540.00 324,000.00
181 Zinc 20 mg Tablet PT. Kimia Farma DAK 2017 D70890J 01/04/2019
9,000 540.00 4,860,000.00
182 Zinc 20 mg Tablet PT. Kimia Farma DAK 2017 C70601J 01/03/2019
10,600 540.00 5,724,000.00
183 Aminophyline Injeksi Ampul PT. Phapros 990 DAK 2017 063070051 01/05/2020 2,998.00
2,968,020.00
184 Aqua DM 1000 ml Botol DAK 2017 AQUADM2017 31/12/2030
303 11,000.00 3,333,000.00
185 Calcium Gluconat Inj 100 mg/ml Ampul PT. Ethica Industri DAK 2017 97LC0107 01/03/2021
456 9,955.00 4,539,480.00
186 Chlorpromazin Injeksi 25 mg/ml Ampul PT. Phapros DAK 2017 95329002 31/08/2019
34 1,291.00 43,894.00
187 Dexamethasone Injeksi Ampul PT. Phapros DAK 2017 06337041BF 01/03/2020
8,600 1,605.00 13,803,000.00
188 Furosemide Injeksi 10 mg/ml Ampul PT. Indofarma DAK 2017
125 IL17A004 01/02/2019 2,700.00 337,500.00
Gentamycin Sulphate Injeks i40
189 Ampul PT. Indofarma DAK 2017
mg/ml 135 BF16J152 01/11/2019 3,556.00 480,060.00
Page 42 of 54
190 Methyl Ergometrin Inj 0,2 mg/ml Ampul PT. Ethica Industri DAK 2017
135 97KL0047 01/12/2019 2,992.00 403,920.00
Page 43 of 54
191 Omeprazole Inj 40 mg/ml Ampul PT. Otto Pharmaceutical DAK 2017
2,334 7D0321 01/04/2019 17,657.00 41,211,438.00
192 Omeprazole Inj 40 mg/ml Ampul PT. Anugrah Argon Medica DAK 2017
6,450 2480763 01/02/2020 12,998.00 83,837,100.00
193 Acyclovir 5% Salep Kulit Tube PT. Indofarma DAK 2017 1708072 01/08/2021
350 3,600.00 1,260,000.00
Antibakteri, kombinasi : basitrasin
194 500 UI/g+ Polimiksin B 10.000 UI/g Tube PT. Indofarma DAK 2017 1706003 01/06/2021
(Bacitracin SK) 1,000 3,071.00 3,071,000.00
Antibakteri, kombinasi : basitrasin
195 500 UI/g+ Polimiksin B 10.000 UI/g Tube PT. Indofarma DAK 2017 1707006 01/07/2021
(Bacitracin SK) 5,625 3,071.00 17,274,375.00
Chloramphenicol 2% Salep Kulit
196 Tube PT. Bufa Aneka DAK 2017 I0205715 01/05/2020
(Bufacetin) 2,918 3,223.00 9,404,714.00
197 Perak Sulfadiazin krim 1% Tube PT. Darya Varia Laboratoria DAK 2017 159LM 01/09/2020
609 20,700.00 12,606,300.00
PT. Jayamas Medica
198 Alcohol 70% Botol DAK 2017 22091788 01/08/2021
Industri
502 28,750.00 14,432,500.00
199 Glucosa 5% (D5%) Botol PT. Widatra Bhakti DAK 2017 270319 01/02/2020
3,040 6,970.00 21,188,800.00
180 7,500.00 1,350,000.00
201 Natrium Chlorida (NaCl) 0,9% Botol PT. Widatra Bhakti DAK 2017 470505 17/04/2019
4,540 6,410.00 29,101,400.00
202 Ringer Asetat (Asering) Botol PT. Otsuka DAK 2017 47D77A 08/04/2020
2,375 9,275.00 22,028,125.00
203 Ringer Laktat Botol PT. Widatra Bhakti DAK 2017 471101 01/10/2021
5,040 7,150.00 36,036,000.00
Anti Tetanus Serum (Tetagam P.
204 Ampul PT. Dexa Medica 10 DAK 2017 35245831J 01/02/2020
Prefiled Syringe 1 ml) 169,999.99 1,699,999.90
Devitalisasi Pasta non Arsen
205 Set Prevest Den Pro Limited DAK 2017 1881606 01/05/2019
(Devitec) / Pulp-X
12 375,000.00 4,500,000.00
206 Ethyl Chloride Kaleng PT. Germany DAK 2017 160921 01/09/2019
93 129,000.00 11,997,000.00
207 Fletcher Kotak DAK 2017 1311733 01/03/2020
8 150,000.00 1,200,000.00
209 Glass ionomer Kotak DAK 2017 1607221 21/07/2019
11 750,000.00 8,250,000.00
Tehno Dent Co. LTD,
210 Iodoform Pasta/Iodotin Pcs DAK 2017 05 01/03/2020
Russia 4 200,000.00 800,000.00
3M ESPE Dental Products,
211 Komposit Tube DAK 2017 N865771 01/10/2020
USA
10 700,000.00 7,000,000.00
212 Spongestan (Hemospon) Kotak DAK 2017 17001 01/02/2020
55 200,000.00 11,000,000.00
Bio Dinamica Quimica e-

213 Tri Kresol Formalin (TKF) Kotak Pharmaceutica LTDA, 9 DAK 2017 76116 01/11/2019 150,000.00 1,350,000.00
Brazil
214 Cynoff Botol PT. Bina Guna Kimia 22 DAK 2017 9500223 01/11/2020
1,484,000.00 32,648,000.00
215 Kaporit Galon PT. Rizki Educalab DAK 2017 060417 660,000.00
31 - 20,460,000.00
DAK 2018 2,277,156,691.58
1,170.00 936,000.00
217 Alat Suntik sekali pakai 1 ml Pcs PT. Anugrah Mitra Selaras 4,290 DAK 2018 1110 09/11/2022
1,170.00 5,019,300.00
Page 44 of 54
218 Alat Suntik sekali pakai 3 ml Pcs Remedi 16,300 DAK 2018 1110 09/11/2022
956.00 15,582,800.00
1,228.50 12,285,000.00
1,579.50 2,369,250.00
Page 45 of 54
PT. Advance Medicare
221 Blade Sterile (Mess) Pcs 590 DAK 2018 7259 01/06/2022
Corpora
11,211.63 6,614,861.70
PT. Advance Medicare
222 Blade Sterile (Mess) Pcs 8,200 DAK 2018 8119 01/03/2023
Corpora
11,211.63 91,935,366.00
Catgut Chromic (Absorbable Suture PT. Jayamas Medica
223 Pcs 6,000 DAK 2018 1709215 01/09/2022
Sterile) Industri
6,141.67 36,850,020.00
43,680.00 3,931,200.00
43,680.00 5,460,000.00
PT. Jayamas Medica
226 Dermafix T 10X12 cm Pcs DAK 2018 30071888 01/06/2023
Industri
97 6,624.00 642,528.00
PT. Jayamas Medica
227 Female Catheter no. 12 Pcs
Industri
71 DAK 2018 08051488 01/04/2019 5,324.00 378,004.00
228 Female Catheter no. 16 Pcs Aximed - Suzhou Weikang

81 DAK 2018 20170820 01/08/2022 7,092.80 574,516.80
PT. Jayamas Medica
229 Foley Catheter no. 18 Pcs
Industri
52 DAK 2018 16-G-15D 01/03/2021 8,800.00 457,600.00
PT. Jayamas Medica
230 Foley Catheter no. 20 Pcs
Industri
40 DAK 2018 17-G-04D 01/03/2022 8,800.00 352,000.00
231 Gel Dopler USG Botol PT. Multiguna
20 DAK 2018 D0616013 01/06/2021 182,701.08 3,654,021.60
232 Infus Set Anak Pcs Stera
8,500 DAK 2018 11091788 01/08/2022 3,850.00 32,725,000.00
233 Infus Set Dewasa Pcs Stera
8,400 DAK 2018 02061788 01/04/2021 3,520.00 29,568,000.00
234 IV Catheter no. 16 Pcs PT. Denar Dana Djaya
450 DAK 2018 160201 01/02/2019 7,775.00 3,498,750.00
4,600 DAK 2018 180131 01/03/2021 7,885.00 36,271,000.00

6,150 DAK 2018 180103 15/01/2021 7,885.00 48,492,750.00
240 Kassa Hidrofil Panjang Rol PT. Anugrah Mitra Selaras

694 DAK 2018 1803 3/1/2023 123,375.00 85,622,250.00
241 Masker Rebreathing Pcs Besmed Health Bussiness
25 DAK 2018 22011888 01/12/2030 27,104.00 677,600.00
242 Masker Rebreathing Pcs Besmed Health Bussiness
26 DAK 2018 27121388 01/12/2030 27,104.00 704,704.00
243 Masker ties on Pcs PT. Vasmedica Spundbond

2,500 DAK 2018 001001001 16/11/2022 753.33 1,883,325.00
PT. Jayamas Medica
244 Nasal Canula Anak Pcs
Industri 26 DAK 2018 10101788 01/12/2030 6,050.00 157,300.00
PT. Jayamas Medica
245 Nasal Canula Dewasa Pcs
Industri 40 DAK 2018 3041788 01/12/2030 6,050.00 242,000.00
PT. Terumo Medical
246 Needle No. 25G x 25 mm Pcs
Product 2,200 DAK 2018 161020 01/09/2021 346.50 762,300.00
247 Needle No. 25G x 25 mm Pcs
3,300 DAK 2018 180120 31/12/2022 346.50 1,143,450.00
Page 46 of 54
248 Plester 5 yard x 2 inc (Hansaplast) Rol PT. Beiersctorf Indo
89 DAK 2018 73754648 01/09/2020 26,244.00 2,335,716.00
250 Sarung Tangan Latex Powder no. S PT. Alexa Medica

5,000 DAK 2018 219052636LCZA 01/12/2022 657.80 3,289,000.00
251 Sarung Tangan Latex Powder no. M Pcs PT. Alexa Medica
9,500 DAK 2018 211042636LCZA 01/09/2022 657.80 6,249,100.00
252 Sarung Tangan Latex Powder no. L Pcs PT. Alexa Medica
4,000 DAK 2018 211047941LCZA 01/09/2022 657.80 2,631,200.00
253 Stomach tube no. 18 Pcs PT. Bio Axion
26 DAK 2018 20170715 01/07/2022 9,138.47 237,600.22
254 Allopurinol 100 mg Tablet PT. Novapharin DAK 2018 1808-02-106 01/08/2020
70,000 194.00 13,580,000.00
255 Amitryptylline 25 mg Tablet PT. Parit Padang Global DAK 2018 A1402AV 01/01/2022
15,000 168.00 2,520,000.00
256 Amlodipin 10 mg Tablet PT. Pharma Laboratories DAK 2018 HL098145 01/11/2020
24,330 95.00 2,311,350.00
257 Amlodipin 10 mg Tablet PT. Pharma Laboratories DAK 2018 AE09H007 01/05/2021
22,560 95.00 2,143,200.00
259 Amoxicillin 500 mg Tablet PT. Mersi DAK 2018 B80134 01/08/2020
192,000 245.00 47,040,000.00
260 Amoxicillin 500 mg Tablet PT. Hexapharm Jaya DAK 2018 CAMXA80382 01/04/2021
24,000 245.00 5,880,000.00
261 Antasida DOEN Tablet Tablet PT. Triman DAK 2018 D8021 01/04/2021
161,900 160.00 25,904,000.00
262 Antasida DOEN Tablet Tablet PT. Triman DAK 2018 E8022 01/05/2021
260,000 160.00 41,600,000.00
263 Asam Ascorbat 50 mg Tablet PT. Kimia Farma DAK 2018 E80078BI 01/04/2021
183,400 110.00 20,174,000.00
264 Asam Folat 1 mg Tablet PT. Marin Liza Farmasi DAK 2018 18TC024 01/03/2020
7,800 74.00 577,200.00
265 Asam Mefenamat 500 mg Tablet PT. Mersi DAK 2018 A80515 01/03/2020
264,400 103.00 27,233,200.00
266 Asetosal 80 mg (Miniaspi) Tablet PT. Mersifarma DAK 2018 A80832 01/02/2020
4,300 99.00 425,700.00
267 Asetyl Sistein 200 mg Kapsul PT. Indofarma DAK 2018 18ASI009 01/04/2020
34,500 376.00 12,972,000.00
268 Asetyl Sistein 200 mg Kapsul PT. Indofarma DAK 2018 18ASI019 01/05/2020
132,000 376.00 49,632,000.00
269 Calcium Lactate 500 mg Tablet PT. Mersifarma 250,000 DAK 2018 A80168 01/04/2020 59.00 14,750,000.00
270 Captopril 12,5 mg Tablet PT. Kimia Farma DAK 2018 D80692B 01/03/2023
10,000 65.00 650,000.00
271 Carbamazepin 200 mg Tablet PT. Mersifarma DAK 2018 A80702 01/03/2020
69,600 231.00 16,077,600.00
272 Cavicur Tablet PT. Erla DAK 2018 H0753017 01/04/2021
1,200 655.00 786,000.00
19,200 655.00 12,576,000.00
93,600 655.00 61,308,000.00
275 Chlorpromazin 100 mg Tablet PT. Mersifarma DAK 2018 A80221 01/02/2022
30,900 605.00 18,694,500.00
276 Ciprofloxacin 500 mg Tablet PT. Novapharin DAK 2018 1807-16-108 31/07/2020
10,000 272.00 2,720,000.00
277 Clindamycin 150 mg Tablet PT. Novell DAK 2018 EBG021 01/07/2020
6,750 729.00 4,920,750.00
278 Dexamethasone 0,5 mg Tablet PT. Novapharin DAK 2018 1807-33-150 31/07/2020
106,200 33.00 3,504,600.00
279 Diazepam 2 mg Tablet PT. Kimia Farma DAK 2018 B802019 01/02/2021
93,900 115.00 10,798,500.00
280 Digoxin 0,25 mg Tablet PT. Yarindo Farma DAK 2018 A8602BV 01/02/2020
3,000 104.00 312,000.00
Page 47 of 54
281 Dimenhydrinat 50 mg Tablet PT. Kimia Farma DAK 2018 D80810B 01/03/2023
7,500 110.00 825,000.00
282 Erytromycin 250 mg Tablet PT. Lucas Djaja DAK 2018 18CD016 01/02/2021
2,700 576.00 1,555,200.00
283 Erytromycin 250 mg Tablet PT. Lucas Djaja DAK 2018 18CC001 01/03/2021
44,200 576.00 25,459,200.00
Page 48 of 54
284 Erytromycin 250 mg Tablet PT. Lucas Djaja DAK 2018 18CD024 01/04/2021
100 576.00 57,600.00
285 Furosemide 40 mg Tablet PT. Kimia Farma DAK 2018 C80551B 01/02/2021
6,400 79.00 505,600.00
286 Glibenclamide 5 mg Tablet PT. Indofarma DAK 2018 1701009 01/04/2022
107,000 125.00 13,375,000.00
2,000 125.00 250,000.00
48,000 125.00 6,000,000.00
289 Glimepiride 1 mg Tablet PT. OGB Dexa DAK 2018 49F0044 01/05/2021
9,400 174.00 1,635,600.00
290 Glimepiride 1 mg Tablet PT. OGB Dexa DAK 2018 49G0068 01/07/2021
60,300 174.00 10,492,200.00
291 Glimepiride 2 mg Tablet PT. OGB Dexa DAK 2018 49F0067 01/05/2021
69,000 207.00 14,283,000.00
292 Griseofulvin 500 mg Tablet PT. Mensa Bina Sukses DAK 2018 AJ12H005 01/09/2020
10,000 892.00 8,920,000.00
293 Haloperidol 1,5 mg Tablet PT. Holi Pharma DAK 2018 A1909DV 01/04/2023
6,800 59.00 401,200.00
295 Ibuprofen 400 mg Tablet PT. Novapharin DAK 2018 1808-07-134 01/08/2020
287,500 281.00 80,787,500.00
296 Ketoconazole 200 mg Tablet PT. Novapharin DAK 2018 1806-01-103 01/06/2020
30,000 286.00 8,580,000.00
Kombipak (Azythromycin +
297 Kotak PT. Kimia Farma DAK 2018 F81832J1 01/09/2020
Cefixime) 195 31,231.00 6,090,045.00
PT. Promedrahardjo
298 Loratadine 10 mg Tablet 266,700 DAK 2018 10218E0020 01/05/2021 125.00 33,337,500.00
Farmasi Industri
299 Metformin 500 mg Tablet PT. Hexapharm Jaya DAK 2018 HTMFNA82699 31/03/2020
100,000 99.00 9,900,000.00
300 Methyl Ergometrine 0,125 mg Tablet PT. Kimia Farma DAK 2018 D81056J 01/04/2023
1,300 221.00 287,300.00
301 Methyl Prednisolone 4 mg Tablet PT. Molex Ayu 100,000 DAK 2018 MO2AA015 01/04/2021 137.00 13,700,000.00
302 Metoclopramide 10 mg Tablet PT. Graha Farma DAK 2018 WK377G 01/11/2020
2,500 80.00 200,000.00
303 Metronidazole 250 mg Tablet PT. Phyto Kemo Agung DAK 2018 BK912712 01/11/2021
21,000 91.00 1,911,000.00
304 Natrium Diclofenac 25 mg Tablet PT. Phapros DAK 2018 16364022 01/06/2023
144,600 132.00 19,087,200.00
3,800 127.00 482,600.00
51,700 127.00 6,565,900.00
307 Nifedipin 10 mg Tablet PT. Kimia Farma DAK 2018 D80821B 01/04/2022
13,000 198.00 2,574,000.00
308 Nystatin 100.000 IU Tablet Vaginal Tablet PT. Phapros DAK 2018 06272013 01/11/2021
3,200 590.00 1,888,000.00
309 Nystatin 500.000 IU Tablet PT. Phapros DAK 2018 16371003 01/04/2021
200 830.00 166,000.00
310 Omeprazole 20 mg Kapsul PT. Novapharin DAK 2018 1807-18-53 01/07/2020
102,600 134.00 13,748,400.00
13,100 160.00 2,096,000.00
1,300 160.00 208,000.00
760,200 160.00 121,632,000.00
314 Prednisone 5 mg Tablet PT. Holi Pharma DAK 2018 1801097 01/01/2020
186,500 72.00 13,428,000.00
Page 49 of 54
315 Propanolol 10 mg Tablet PT. Holi Pharma DAK 2018 1803041 01/03/2021
20,000 57.00 1,140,000.00
Page 50 of 54
316 Propylthiouracil 100 mg Tablet PT. OGB Dexa DAK 2018 49G0625 01/06/2022
23,300 453.00 10,554,900.00
317 Ranitidine 150 mg Tablet PT. Holi Pharma DAK 2018 1802087 01/02/2020
15,500 110.00 1,705,000.00
318 Risperidone 1 mg Tablet PT. OGB Dexa DAK 2018 49F0242 01/06/2021
9,700 228.00 2,211,600.00
319 Risperidone 2 mg Tablet PT. OGB Dexa DAK 2018 49A0045 01/12/2020
13,100 273.00 3,576,300.00
320 Salbutamol 4 mg Tablet PT. Graha Farma DAK 2018 YC313G 01/03/2022
100,000 74.00 7,400,000.00
321 Simvastatin 10 mg Tablet PT. Yarindo Farmatama DAK 2018 A8729DV 01/04/2020
17,100 110.00 1,881,000.00
322 Simvastatin 20 mg Tablet PT. Tempo Scan Pasific DAK 2018 022678 01/02/2020
5,000 214.00 1,070,000.00
323 Simvastatin 20 mg Tablet PT. Tempo Scan Pasific DAK 2018 031008 01/03/2020
10,000 214.00 2,140,000.00
324 Thiamin HCl (Vitamin B1) 50 mg Tablet PT. Novapharin DAK 2018 1808-15-158 01/06/2022
80,000 85.00 6,800,000.00
325 Vitamin B Kompleks Tablet PT. Kimia Farma DAK 2018 B80419T 01/02/2021
355,800 123.00 43,763,400.00
326 Vitamin B Kompleks Tablet PT. Kimia Farma DAK 2018 C80432T 01/03/2021
37,600 123.00 4,624,800.00
327 Zinc 20 mg Tablet PT. Kimia Farma DAK 2018 G82019J 01/07/2020
200,000 551.00 110,200,000.00
328 Amoxicillin Syr 125 mg/5ml Botol PT. Mersi Farma DAK 2018 270568 01/12/2019
11,400 4,999.60 56,995,440.00
329 Amoxicillin Syr 125 mg/5ml Botol PT. Novapharin DAK 2018 1807-04-96 01/07/2020
126 4,999.60 629,949.60
330 Amoxicillin Syr 125 mg/5ml Botol PT. Novapharin DAK 2018 1808-04-96 01/08/2020
5,794 4,999.60 28,967,682.40
331 Antasida DOEN Suspensi Botol PT. Lucas DAK 2018 18SG331 01/07/2020
11,850 2,051.00 24,304,350.00
PT. Mersifarma Tirmaku
332 Cotrimoxazol Suspensi 240 mg/5ml Botol DAK 2018 A80996 01/05/2020
Mercusana 7,400 2,052.00 15,184,800.00
333 Domperidon Suspensi 5 mg/ml Botol PT. Novapharin DAK 2018 1806-11-186 01/06/2020
2,100 2,781.00 5,840,100.00
334 Metronidazol Suspensi 125 mg/5ml Botol PT. Meprofarm DAK 2018 E7H422 01/08/2019
80 3,950.00 316,000.00
335 Paracetamol Sirup 120 mg/5ml Botol PT. Novapharin DAK 2018 1808-31-86 01/08/2022
27,300 3,850.00 105,105,000.00
336 Paracetamol Sirup 120 mg/5ml Botol PT. Novapharin DAK 2018 1809-28-86 01/09/2022
2,750 3,850.00 10,587,500.00
337 Ampicillin Injeksi 1000 mg Vial PT. Phapros 920 DAK 2018 16426026 01/06/2020 8,649.00
7,957,080.00
338 Chlorpromazin Injeksi 5 mg/ml Ampul PT. Phapros DAK 2018 95330003 31/08/2019
150 1,585.00 237,750.00
339 Combivent Ampul PT. Boehringer DAK 2018 7984013 31/11/2019
4,120 4,550.00 18,746,000.00
340 Dexamethasone Injeksi Ampul PT. Meprofarm DAK 2018 30846 01/02/2020
300 1,152.00 345,600.00
341 Diazepam Injeksi 5 mg/ml Ampul PT. Indofarma DAK 2018 F8B244 01/02/2020
1,095 4,389.00 4,805,955.00
342 Diphenhydramine HCl Inj 10 mg/ml Ampul PT. Lucas Djaja DAK 2018 18IB001 01/02/2021
2,310 1,152.00 2,661,120.00
343 Ephinefrin Injeksi 1 mg/ml Ampul PT. Ethica Industri DAK 2018
550 97LI0122 01/09/2020 1,408.00 774,400.00
344 Haloperidol Dekanoat Inj 50 mg/ml Ampul PT. Soho Industri Pharmasi DAK 2018
15 582T 01/05/2021 101,300.00 1,519,500.00
345 Lidocain Compositum Injeksi Ampul PT. Phapros DAK 2018
5,037 16815003-2 31/01/2021 1,205.00 6,069,585.00
Page 51 of 54
346 Methyl Ergometrin Inj 0,2 mg/ml Ampul PT. Ethica Industri DAK 2018
300 97LH0031 01/08/2020 3,102.00 930,600.00
347 Oxytocin Injeksi 10 IU/ml Ampul PT. Ethica Industri DAK 2018
1,500 968E0062A 01/05/2020 1,199.00 1,798,500.00
348 Oxytocin Injeksi 10 IU/ml Ampul PT. Ethica Industri DAK 2018
4,800 97LK0057 01/10/2020 1,199.00 5,755,200.00
349 Phenobarbital Injeksi 50 mg/ml Ampul PT. Rajawali Nusindo DAK 2018
20 95803003-2 01/08/2020 1,950.00 39,000.00
350 Phytomenadion Inj 2 mg/ml Ampul PT. Phapros DAK 2018
630 06478065 01/11/2019 3,867.00 2,436,210.00
351 Antifungi Pot PT. Indofarma DAK 2018 18SD001A 01/04/2022
360 4,721.00 1,699,560.00
352 Betamethasone cream Tube PT. Kimia Farma DAK 2018 E81079T 01/05/2021
6,950 1,373.00 9,542,350.00
353 Chloramphenicol 1% Salep Mata Tube PT. Kimia Farma DAK 2018 E81577W 01/05/2021
4,368 1,925.00 8,408,400.00
Chloramphenicol 2% Salep Kulit
354 Tube PT. Bufa Aneka DAK 2018 I0208801 01/08/2021
(Bufacetin)
1,000 3,171.00 3,171,000.00
Chloramphenicol Tetes Telinga
355 Botol PT. Erella DAK 2018 D0653031 01/01/2020
(Erlamycetin)
673 8,000.00 5,384,000.00
Chloramphenicol Tetes Telinga
356 Botol PT. Erella DAK 2018 D0653034 01/07/2021
(Erlamycetin) 1,064 8,000.00 8,512,000.00
357 Hydrocortison 2,5% cream Tube PT. Kimia Farma DAK 2018 E81177T 01/05/2022
4,800 2,533.00 12,158,400.00
358 Ketoconazole Cream 2% Tube PT. Kimia Farma DAK 2018 H71260T 01/08/2021
250 2,577.00 644,250.00
359 Oxytetrasiklin Salep Mata 1% Tube PT. Kimia Farma DAK 2018 D81127W 01/04/2021
375 2,600.00 975,000.00
360 Salep-24 Pot PT. Holi Pharma DAK 2018 4803032 01/03/2022
1,533 2,750.00 4,215,750.00
361 Antihemoroid Suppo Supp PT. Kimia Farma DAK 2018 I72227W 01/09/2021
1,130 3,325.00 3,757,250.00
Diazepam Lar. Rektal 5 mg/2,5 ml
362 Ampul PT. Mensa Bina Sukses DAK 2018 V23681703 31/05/2020
(Stesolid) 50 13,202.00 660,100.00
363 Antiseptik Kumur Botol PT. Mahakam Beta Farma DAK 2018 DB81024 01/03/2021
817 11,550.00 9,436,350.00
PT. Jayamas Medica
364 Etakridin (Rivanol) Botol DAK 2018 10011788 01/12/2019
Industri 363 3,450.00 1,252,350.00
Hand Rub (E Care Cairan Antiseptik
365 Botol PT. Tri Sapta Jaya DAK 2018 180109E 01/01/2021
500 ml)
78 63,840.00 4,979,520.00
Hand Wash (E Care Sabun Cair 500
366 Botol PT. Tri Sapta Jaya DAK 2018 PP170502 30/05/2020
ml) 125 70,917.00 8,864,625.00
PT. Jayamas Medica
367 Lysol Botol DAK 2018 22111788 01/10/2020
Industri 3 47,150.00 141,450.00
PT. Jayamas Medica
368 Lysol Botol DAK 2018 04121788 01/11/2020
Industri 120 47,150.00 5,658,000.00
4,980 6,900.00 34,362,000.00
500 7,500.00 3,750,000.00
371 Natrium Chlorida (NaCl) 0,9% Botol PT. Widatra Bhakti DAK 2018 280102 01/12/2022
7,960 6,410.00 51,023,600.00
372 Ringer Asetat (Widabes) Botol PT. Widatra Bhakti DAK 2018 280201 01/01/2020
1,760 9,646.00 16,976,960.00
373 Ringer Laktat Botol PT. Widatra Bhakti DAK 2018 370514 01/04/2022
17,120 7,150.00 122,408,000.00
Anti Tetanus Serum (Tetagam P.
374 Ampul PT. Dexa Medica 88 DAK 2018 35845821B 01/08/2020
Prefiled Syringe 1 ml)
176,800.00 15,558,400.00
375 Serum Anti Bisa Ular (ABU) Vial PT. Biofarma 89 DAK 2018 4700718 01/05/2020
479,966.00 42,716,974.00
Page 52 of 54
376 Benecheck Asam Urat Kotak PT. Mitra Asa Pratama DAK 2018 U18099060 01/12/2019
7 156,558.44 1,095,909.08
Page 53 of 54
377 Benecheck Glucosa Kotak PT. Mitra Asa Pratama DAK 2018 G18148067 01/06/2020
2 174,957.59 349,915.18
378 Abate Sachet PT. BASF Indonesia 5,000 DAK 2018 1701020001 11/01/2019
3,814.00 19,070,000.00
379 Alat Suntik Sekali Pakai 0.05 ml Pcs PT. Skifa Ananta Dharma DAK 2018 1707401 1,456.00
4000 01/02/2022 5,824,000.00
380 Alat Suntik Sekali Pakai 5 ml Pcs PT. Skifa Ananta Dharma DAK 2018 1707401 1,685.00 6,740,000.00
4000 01/02/2022
381 Salbutamol 2 mg Tablet PT. Graha Farma DAK 2018 XJ248G 01/10/2021
26,400 64.00 1,689,600.00
GAVI 2018 9,009,600.00
382 Alat Suntik Sekali Pakai 0.5 ml Pcs PT. Skifa Ananta Dharma GAVI 2018 1808409 1,877.00 9,009,600.00
4800 01/03/2023
PROGRAM ATAU LAIN-LAIN 330,449,840.00
383 Formalin Botol - Lain-Lain 2014 - 50,000.00
7 01/01/2025 350,000.00
Anti - HIV 1/2 Test ONE STEP -
384 Paket Depkes PROGRAM D3AMC002A 01/08/2019
Bio Line 3 1,434,000.00 4,302,000.00
385 Isoniazid Tablet Lupin PROGRAM A4D0517B 01/09/2019
2,500 75.00 187,500.00
386 MDT Combi Dewasa Paket Depkes PROGRAM BHE6751 01/03/2021
27 189,420.00 5,114,340.00
PROGRAM MR 22,408,800.00
388 Alat Suntik Sekali Pakai 0.5 ml Pcs PT. Skifa Ananta Dharma PROGRAM MR 1804407 1,877.00 21,397,800.00
11400 01/03/2023
389 Alat Suntik Sekali Pakai 5 ml Pcs PT. One Jet PROGRAM MR 165021 1,685.00 1,011,000.00
600 01/04/2021
PUSAT 2018 18,019,200.00
390 Alat Suntik Sekali Pakai 0.5 ml Pcs PT. Skifa Ananta Dharma PUSAT 2018 1808409 1,877.00 18,019,200.00
9600 01/03/2023
RELOKASI 2018 0.00
391 OBH Sirup Botol PT. Erella RELOKASI18 2550023 01/02/2019
35 0.00 0.00
392 Thiamin HCl (Vitamin B1) 50 mg Tablet PT. Sejahtera Lestari Farma RELOKASI18 53509 01/08/2019
14,000 0.00 0.00
393 Trihexiphenidil HCl 2 mg (Heximer) Tablet PT. Mersifarma RELOKASI18 150315 01/05/2019
26,000 0.00 0.00
Page 54 of 54

Pencacahan 31 Des 18 REVISI METODE PERHITUNGAN PART 3

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Pencacahan 31 Des 18 REVISI METODE PERHITUNGAN PART 3

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LAMPIRAN BERITA ACARA PENCACAHAN OBAT DI UPTD IFK DOMPU

PERIODE 31 DESEMBER 2018

Bahan Medis Habis Pakai 437,835,360.00

Obat - Obatan 462,869,128.00

Injeksi dan Pelarut 6,079,800.00

Tetes Mata, Tetes Telinga, Salep dan Sed. Topikal 3,120,000.00

DANA DAK 4,586,599,755.70

Obat - Obatan 1,936,743,880.00

Sirup, Suspensi dan Drop 268,873,462.00

Injeksi dan Pelarut 245,308,472.00

Tetes Mata, Tetes Telinga, Salep dan Sed. Topikal 120,613,865.00

Suppositoria dan Larutan Rektal 4,417,350.00

Antiseptik dan Desinfektan 121,240,205.00

Larutan Elektrolit dan Cairan Infus 338,224,885.00

Vaksin dan Serum 59,975,373.90

Preparat Gigi 49,037,000.00

Bahan Kimia 136,062,500.00

Relokasi Dari Dana JKN Puskesmas 0.00

Bahan Medis Habis Pakai 437,581,770.00

Obat - Obatan 461,869,642.00

Injeksi dan Pelarut 6,079,800.00

Tetes Mata, Tetes Telinga, Salep dan Sed. Topikal 3,120,000.00

DANA DAK 4,577,265,287.94

Obat - Obatan 1,939,184,800.00

Sirup, Suspensi dan Drop 268,873,462.00

Injeksi dan Pelarut 223,830,536.00

Tetes Mata, Tetes Telinga, Salep dan Sed. Topikal 120,407,769.00

Suppositoria dan Larutan Rektal 4,417,350.00

Antiseptik dan Desinfektan 121,350,585.00

Larutan Elektrolit dan Cairan Infus 338,012,085.00

Vaksin dan Serum 60,043,374.00

Preparat Gigi 49,037,000.00

Bahan Kimia 136,062,500.00

Relokasi Dari Dana JKN Puskesmas 2,325,750.00

Bahan Medis Habis Pakai 437,581,770.00

Obat - Obatan 461,869,642.00

Injeksi dan Pelarut 6,079,800.00

Tetes Mata, Tetes Telinga, Salep dan Sed. Topikal 3,120,000.00

DANA DAK 4,577,265,287.94

Obat - Obatan 1,939,184,800.00

Sirup, Suspensi dan Drop 268,873,462.00

Injeksi dan Pelarut 223,830,536.00

Tetes Mata, Tetes Telinga, Salep dan Sed. Topikal 120,407,769.00

Antiseptik dan Desinfektan 121,350,585.00

Larutan Elektrolit dan Cairan Infus 338,012,085.00

Vaksin dan Serum 60,043,374.00

Preparat Gigi 49,037,000.00

Bahan Kimia 136,062,500.00

Relokasi Dari Dana JKN Puskesmas 2,325,750.00

E-LOGISTIK PRODUSEN TANGGAL HARGA

APBN PUSAT 2018

71 IV Catheter no. 16 Pcs PT. Otsuka

Aximed - Zhejiang Kindly

PT. Jayamas Medica

PT. Jayamas Medica

129 Aquadest Botol 1 Liter

138 Foley Catheter no. 18 Pcs PT. Anugrah Mitra Selaras

139 IV Catheter no. 18 Pcs PT. Anugrah Mitra Selaras

141 IV Catheter no. 22 Pcs PT. Anugrah Mitra Selaras

142 IV Catheter no. 24 Pcs PT. Anugrah Mitra Selaras

PT. Jayamas Medica

PT. Rama Emerald Multi

Bio Dinamica Quimica e-

228 Female Catheter no. 16 Pcs Aximed - Suzhou Weikang