(Rev 04-03-2021) LAPORAN HASIL RAPAT FORMULARIUM GLOBAL

HASIL RAPAT FORMULARIUM
CAIRAN
No NAMA SEDIAAN KOMPOSISI
1 Aerrane 250ml Isoflurane Baxter
tiap mL mengandung NaCl 0.64%, KCl

2 BSS 25ML 0.075%, CaCl2•2H2O 0.048%, MgCl2•6H2O
0.03%, C2H3NaO2•3H2O 0.39%,
C6H5Na3O7•2H2O 0.17%, HCl, dan water
for injection
Kalium 18 meq. Kalsium 4 meq. Magnesium

3 FUTROLIT (500 ML) 6 meq. Asetat 38 meq (natrium klorida
3,624 g, kalium klorida 1,342 g, kalsium
klorida 0,294 g, magnesium hidroksida 0,61
g, natrium asetat 5,172 g, air untuk injeksi
hingga 1000 ml
Per 1000 mL Na 130 meq, Cl 109 meq, K 4

4 meq, Ca 2.7 meq, lactate 20 meq, maltose
50 g, (NaCl 6 g, KCl 0.3 g, CaCl2 0.2 g, Na
lactate 3.1 g, water for inj 1,000 mL).
HYDROMAL Osmolaritas: 412 mOsm. Energi: 220 kkal.
5 INFUSAN D5 DP (500 ML) Dextrose Anhydrate 5%
Tiap 500 mL mengandung Glucose

6 INFUSAN D5+1/2 NS DP Monohydrate/Glucose 25 gram, Sodium
Chloride/NaCl 2,25 gram
7 INFUSAN D5+1/4 NS DP Per 1000 mL Na 38.5 meq, Cl 38.5 meq,

dextrose 50 g, (NaCl 2.25 g). Osmolaritas:
355 mOsm. Energi: 200 kkal
8 Per 1000 mL Mannitol 200 g. Osmolaritas:
INFUSAN M20 1098 mOsm
9 INFUSAN NS 100 ML Na 154 mEq, Cl 154 mEq
10 INFUSAN NS DP (500ML) Na 154 mEq, Cl 154 mEq

11 INFUSAN R+ D DP (500ML) meq, Ca 4.4 meq, dextrose 50 g, (NaCl 18.6
g, KCl 0.3 g, CaCl2 0.48 g). Osmolaritas: 586
mOsm.
12 INFUSAN RING AS DP (500 ML) Per 1000 mL Na 131 meq, Cl 109 meq, K 4
meq, Ca 2.7 meq, acetate 28 meq, (NaCl 6
g, KCl 0.3 g, CaCl2 0.2 g, Na acetate 3.8 g
13 INFUSAN RL DP (500 ML) Per 1000 mL Na 130 meq, Cl 109 meq, K 4

meq, Ca 2.7 meq, lactate 28 meq, (NaCl 6 g,
KCl 0.3 g, CaCl2 0.2 g, Na lactate 3.1 g
NaCl 0,64%, KCl 0,075%, CaCl2 0,048%,

14 Kalvisol MgCl2 0,03%, Na acetate 0,39%, Na citrate
0,17%
Sodium Chloride 640mg, Potassium

Chloride 75mg, Calcium Chloride Dihydrate
15 MIRIWASH 500ML 48mg, Magnesium Chloride Hexahydrate
30mg, Sodium Acetate Trihydrate 390mg,
Aqua Pro Injection Ad 100ml
16 PROANES (20 ml) Propofol 10 mg/ml

17 SANMOL INFUS Paracetamol 1000 mg
18 Sevoflurane Baxter Sevoflurane
TAMBAHAN PRODUK BARU
Kalium 18 meq. Kalsium 4 meq. Magnesium

19 FUTROLIT (500 ML) BPJS 6 meq. Asetat 38 meq (natrium klorida
3,624 g, kalium klorida 1,342 g, kalsium
klorida 0,294 g, magnesium hidroksida 0,61
g, natrium asetat 5,172 g, air untuk injeksi
hingga 1000 ml

meq, Ca 2.7 meq, lactate 20 meq, maltose
20 HYDROMAL BPJS 50 g, (NaCl 6 g, KCl 0.3 g, CaCl2 0.2 g, Na
lactate 3.1 g, water for inj 1,000 mL).
Osmolaritas: 412 mOsm. Energi: 220 kkal.
Tiap 500 mL mengandung Glucose

21 INFUSAN D5+1/2 NS SP BPJS Monohydrate/Glucose 25 gram, Sodium
Chloride/NaCl 2,25 gram
22 INFUSAN D5+1/4 NS SP BPJS Per 1000 mL Na 38.5 meq, Cl 38.5 meq,

dextrose 50 g, (NaCl 2.25 g). Osmolaritas:
355 mOsm. Energi: 200 kkal
23 INFUSAN NS SP (500ML) BPJS Na 154 mEq, Cl 154 mEq
24 INFUSAN R+ D SP (500ML) BPJS meq, Ca 4.4 meq, dextrose 50 g, (NaCl 18.6
g, KCl 0.3 g, CaCl2 0.48 g). Osmolaritas: 586
mOsm.
25 INFUSAN RING AS SP (500 ML) BPJS Per 1000 mL Na 131 meq, Cl 109 meq, K 4
meq, Ca 2.7 meq, acetate 28 meq, (NaCl 6
g, KCl 0.3 g, CaCl2 0.2 g, Na acetate 3.8 g
26 INFUSAN RL SP (500 ML) BPJS Per 1000 mL Na 130 meq, Cl 109 meq, K 4
meq, Ca 2.7 meq, lactate 28 meq, (NaCl 6 g,
KCl 0.3 g, CaCl2 0.2 g, Na lactate 3.1 g
ALKES
27 AOK CRESCENT KNIFE BEVEL UP
28 AOK MICRO KNIFE 15.0 DEG STR
29 CLEAR CUT SB 2.75 MM ANGLED
30 Crescent Bevel UP 2,3mm-MCU26 MANI
31 MANI TROCAR KIT 23G 3 pcs Trocar, 1 pcs Infusion Cannula
32 Slit Angled 2.75mm-MANI
33 Straight 15˚- MANI
BHP
34 1764G - MERSILENE 5/0 S24 DA Braided,synthetic green/undyed (white)
35 23GA CURVED MEMBRAN SCRAPPER Scrapper

36 ADV DSP Backfl SOFT TIP 23G Fluid Needle
37
ALKOHOL 70% 100ML Etanol 70%
38 ALKOHOL 70% 1LT Etanol 70%
39
ALKOHOL SWAB 100 STRIP (ONEMED)
Ethyl Alcohol 70%,Chlorhexidine Gluconate
40
ASEPTAN 5 LITER 0,5%
41
ASEPTAN 500 ML + DISP 0,5%
42
ASEPTAN 500 ML REFILL 0,5%
43 etil alkohol 70%, deinoze water, carbomer,

ASEPTIC GEL 5 LITER TEA, PEG 40
ASEPTIC GEL 500 ML REFILL TEA, PEG 40
ASEPTIC GEL 500ML + DISP TEA, PEG 40
46 AUROCOAT 2% Sodium Hyaluronate 20 mg/ml +
Chondroitin Sulphate 20 mg/ml
AUROVISC HPMC 2% 2 ml single use glass
47 HPMC 20 mg/ml
syringe - Eco Pack 5 x 2 ml sterile
48 BBT Visc 1,5% Sodium Hyaluronate 15 mg/ml
49 BIPOLAR CABLE AMO K106075
50 BLOOD LANCET 26G ONEMED
51 BLOOD LANCET 28G ONEMED
52 BLUE TIPS 500'BH (ONEMED)
53 BVI SPEARS
54 CASSETE SIGNATURE OPO70
55 DISP SY W/ONEEDLE 50CC
56 DK LINE
57 Endo probe
58 ENDOTRACHEAL TUBE CUFFED NO 6.0
62 ENDOTRACHEAL TUBE WITH CUFF NO 8.0
63 ETHILON BLK 12IN 8-0 D/A TG175-9 Monofilament,synthetic black
64 EYE DRAPE PRE CUT- Surgitech
65 EYE DRAPE REGULER - Surgitech
66 GLAUCOMA SHUNT AADI 350
67 GUEDEL AIRWAY ALLSIZE (ONEMED)
68 HANSAPLAST PLESTER (BSN)
69 HEALON GV
70 HYPAFIX 5 X 5 (BSN)
71 ID BAND DWS BLUE ONEMED
72 ID BAND DWS PINK ONEMED
73 INFUSION SET DEWASA STERA NEW
74 KASA STERIL 16x16 ONEMED
75 KATENA K20-2054
76 KATENA K20-2056 BARRON VACUUM TREPHINE 7,5MM
79 KATENA K20-2074 BARRON CORNEAL PUNCH 7,0MM
82 KATENA K20-4500 MARKIN PEN STANDARD
83 KIT,SMALL PART,LEGACY MTMS sleeve ungu
84 MASKER BEDAH HIJAU BOX ISI 50PCS
85 MASKER BEDAH HIJAU/KUNING SUPER SOFT
ISI 50PCS
86
MASKER BEDAH JILBAB HIJAU BOX ISI 50PCS
87 MASKER BEDAH TALI BOX ISI 50PCS
88 MAXIFLOW ANAK BH (BESMED)
89 MAXIFLOW ANAK DEWASA BH (BESMED)
90 MICROSMOOTH MICROTIP PARTS KIT sleeve ungu
91 MICROVISC 1% Sodium Hyaluronate 10 mg/ml
92 MORIA DONOR PUNCH 17200DXXX
93 MORIA M20SU @BOX HEAD 90
Head for Art. Chamber steril/single use P/N
94 MORIA OUP LC 350
MOR19184
95 MORIA VACUUM ADJUSTABLE TREPHINE 17202DXXX
96 NEEDLE 20 G X 38 MM
103 NURSE CAP GREEN
104 ONE DOT ECG ELETRODE ANAK BAG ISI 50
(AM 123) 50PCS
105 ONE DOT ECG ELETRODE DEWASA BAG ISI 50
(AM 122) 50PCS
106 ONE SCRUB 4% GALON 5LT Chlorhexidine Gluconated 4%
107 OXFLOW SOFT (BUBBLE) ANAK (BESMED)
108
OXFLOW SOFT (BUBBLE) DEWASA (BESMED)
109 PCR TUBE 1.5ML
110 POV IODINE 30 ML povidon iodine 10 %
111 POV IODINE 60 ML povidon iodine 10 %
112 Q-VISC
113 SAFEGLOVE SURGICAL PF 6; 6,5; 7; 7,5

(SAFEGLOVE)
114 SILICON OIL 1300 OXANE
115 SILICON OIL 5700 OXANE
116 SILICONE I/A TIP,BENT,4EA I/A tip, silikon, bengkok
117 SILICONE I/A TIP,STRAIGHT,4EA I/A tip, silikon, lurus
118 SOFNOLIME
119 SPUIT 10CC ONEMED 100BH
120 SPUIT 1CC TB ONEMED 100BH
123 ST. SENSI GLOVES (M) 100BH/ MAXTER EXAM
(SENSI)
124 ST. SENSI GLOVES (S) 100BH/ MAXTER EXAM
(SENSI)
125 STERILE POUCH 10 CM X 200 M (ONEMED)
126 STERILE POUCH 15 CM X 200 M (ONEMED)
127 STIKPAN PLS DELUXE BLUE BH
128 SUCTION CATH+FINGER 08; 10; 12; 16; 18
129 SURGEON CAP/DOCTOR CAP 100BH
130 SYRINGE 10 CC
131 SYRINGE 3 CC
132 SYRINGE 5 CC
133 SYRINGE WITHOUT N.20CC
134 TEGADERM 1623 W
135 TEGADERM 1624 W
TRYPAN BLUE Solution 0.06 mg/ml Sterile
136 TQM BLUE Isotonic q.s
137 TQM CHOL
OPTHALMIC DRAPE - SIZE 100X70cm
138 TQM DRAPE E-10070
SINGLE LAYER
139 TRANSPORE 1527-0
140 TRANSPORE 1527-1
141 TUBERCULIN 1CC
142 URINAL PLASTIK LK
143 USG GEL 250 ML ONEMED
144 VACULAB 3ML EDTA K3 GLASS
145 VACULAB CITRAT 3.2% 2,7mL 100pcs
146 VIRNA ROHTO Glaucoma Implant
147 VISCOAT 0.75 ML OVD dispersive
148 VISCOUS FLUID SYSTEM PACK
149 VISIDRAPE DUAL BVI 581096
150 W1718 - ETHILON 10/0 6MM D/A Monofilament,synthetic black
151 W8005T - PROLENE 6/0 16 MM P Monofilament,synthetic blue (clear)
152 W9552 - VICRYL CTD 6/0 8 MM SPAT 0.25C Braided.synthetic dyed & undyed
153 W9560 - VICRYL CTD 8/0 6MM SPAT D Braided.synthetic dyed & undyed
154 W9561 - VICRYL CTD 7/0 6MM D Braided.synthetic dyed & undyed
155 YELLOW TIPS '1000S (ONEMED)
156 HEALON GV PRO Viscoelastic 0.5 ml; 0.85 ml
157 OZYM 1 LT (ONEMED)
158 SPC MASKER KN95
159 Hydroxypropyl methylcellulose, 2 ml pre-
KALVIS filled syringe
INJEKSI
160 Anbacim inj Cefuroxime inj
161 Asam Traneksamat 500mg/5ml inj Asam tranexamat 500 mg/5 ml
162 Cefotaxime 1gr injeksi Cefotaxime 1 gr
163 Ceftazidime inj 1 gr Ceftazidime inj 1 gr
164 Ceftazidime inj 1 gr Ceftazidime inj 1 gr
165 Ceftriaxone Sodium 1g injeksi serbuk Ceftriaxone sodium
166 Cefxon inj Ceftriaxone sodium
167 CORTIDEX INJ DEXAMETHASONE
168 CURACIL INJ Fluorouracil 500 mg/10 ml
169 Dexamethasone 5mg/ml injeksi Dexamethasone 5mg/ml
170 DIFENHYDRAMINE HCL 150 MG/15 ML INJ DIFENHYDRAMINE HCL
171 EYLEA INJEKSI AFLIBERCEPT 2MG/0,05ML-VIAL
172 Fortanest 15mg inj Midazolam
173 Fortanest 5mg inj Midazolam
174 Ketorolac 30mg Inj Ketorolac
175 Ketorolac 30mg Inj Ketorolac
176 Lacedim inj Ceftazidime inj 1 gr
177 Lactopain inj 30 mg Ketorolac
178 Lidocain 2% inj @ampul bundar Lidocain
179 Meropenem 1g serbuk injeksi Meropenem 1g
180 Merotik injeksi 1g Meropenem 1g
181 Methylprednisolone 125mg inj Methylprednisolone
182 Ondansetron 4mg/2ml injeksi Ondansetron
183 Ondansetron inj 4mg/2ml Ondansetron
184 PATIZRA INJ Ranibizumab inj 10 mg/ml
185 Ranitidin 50mg/2ml Inj Ranitidin 50mg/2ml Inj
186 Ranitidin 50mg/2ml Inj Ranitidin 50mg/2ml Inj
187 RATIVOL INJEKSI 30 KETOROLAC INJ 30
188 Rocuronium Bromide 50mg/5ml injeksi Rocuronium Bromide
189 Rocuronium Bromide 50mg/5ml injeksi Rocuronium Bromide
190 SANSULIN INSULIN Insulin Long-Acting
191 SANTAGESIK INJ METAMIZOLE
192 TOMIT INJ Metoclorpramide 5 mg/ml
193 TROVENSIS INJ 4MG/2ML ONDANCENTRON
194 TROVENSIS INJ 8MG/4ML ONDANCENTRON
195 VITAMIN K INJEKSI VITAMIN K INJEKSI
IOL
196 ACRYSOFT IQ SN60WF 15.0 - 30.0D Monofocal, natural, UV block, BLF, Aspheric
197 ACRYSOFT SINGLE PIECE SA60AT 0.6-30.0D Monofocal, single piece, UV block
198 CARTRIDGE D cartridge D

Capsular Tension Ring - Clear-single piece
199 CIONNI CTR CC11LR
PMMA ( Single Use )
200 EPOCH INTRAOCULAR LENSA EP -525A, EP-551A, EP-651A, EP-6125A
Foldable Hydrophlic Hemafold FS6025
201 Foldable Hydrophlic Hemafold Diameter Optic 6.00Mmm; Overall
diameter 12.50mm; A cont 118.00 AC
Depth 2.40mm
202 IQ PanOptix IOL 13.0D s.d 31.0D Trifocal IOL
203 IQ PanOptix T2 13.5D s.d 25.0D Trifocal Toric T2
208 LIBERTY IRIS CLAW LENS, INDIA Polymethylmethacrylate/ Acrylic IOL
Hidrophilic Acrylic Injectable IOL with
209 Rayner Cflex Aspheric (power < + 15,00 s/d
+25,00) Amon-Apple Enhanced Square Edge
Intraocular lens, Rayacryl (hydrophilic
210
Rayone Aspheric (power -10,00 s/d +34,00) acrylic)
211 Rayone Hydrophobic (power -10,00 s/d Intraocular lens, hydrophobic aspheric
+34,00)
212 ROHTO NEO EYE RP-12 PC PMMA IOL
213 ROHTO NEO EYE RP-12 PC PMMA IOL DIOPTRI KECIL
214 ROHTO NEO EYE TR-1311 Tension Ring
215 ROHTO NEW -I RF-22L FOLDABLE IOL
216 SENSAR FOLDABLE IOL WITH OPTIEDGE +6.0 D to +30.0 Diopters

(AR40e)
217 SENSAR FOLDABLE IOL WITH OPTIEDGE +2.0 D to +5.5 Diopters
(AR40E)
218 TECNIS MONOFOCAL 1-PIECE INTRAOCULAR ZCB (+5.0 to 34.0)
LENS ZCB00
219 AT TORBI 709M/MP IOL MONOFOCAL TORIC
220 AT LISA TRI 839MP IOL TRIFOCAL
221 AT LISA TRI TORIC 939MP IOL TRIFOCAL TORIC
Capsular Tension Ring - Clear-single piece
222 CTR 10 mm and CTR 11 mm
PMMA ( Single Use )
223 SENSAR FOLDABLE IOL WITH OPTIEDGE -10.0 D to +1.5 Diopters
(AR40M)
224 SN6AT3.6.0 D s.d 30.0D Monofocal Toric T3
225 SN6AT4.6.0D s.d 30.0D Monofocal Toric T4
231 Sulcoflex Trifocal Rayacryl, akrilik hidrofilik, IOL
ZCT100, ZCT150, ZCT225, ZCT300, ZCT375,
232 TECNIS ASPHERIC IOL, TORIC ZCT400, ZCT450, ZCT525, ZCT600, ZCT700,
ZCT800
233 TECNIS EYHANCE INTRAOCULAR LENS ICB00 (+5,0 to +34.0)
234 TECNIS SYNERGY OPTIBLUE INTRAOCULAR ZFR00V (+5.0 to +34.0)

LENS
Preloaded ACRYSOF IQ SN60WF :

235 ULTRASERT V3.5 0.6-27.0D
Monofocal, natural, UV block, BLF, Aspheric
IOL MONOFOCAL ASPHERIC NON PRE-

236 CT ASPHINA 409MP LOADED
237 AT LARA 829MP IOL eDOF
238 AT LARA TORIC 929MP IOL EDOF TORIC
ARTISAN APHAKIA + NEEDLEOPHTEC
239 IOL IRIS CLAW
OPHTEC ENCLAVATION NEEDLE OD125 IOL
ARTISAN MYOPIA + NEEDLE OPHTEC

240 PHAKIC IOL PMMA REFRACTIVE
OPHTEC ENCLAVATION NEEDLE OD125
ARTIFLEX MYOPIA + NEEDLE OPHTEC
241 OPHTEC ENCLAVATION NEEDLE OD125 PHAKIC IOL FOLDABLE REFRACTIVE
ARTIFLEX INSERTION SPATULA
TETES MATA
NO NAMA SEDIAAN KOMPOSISI
242 Albuvit 15% (5ML) Sulfacetamide Sodium 150mg
243 Asthenof (5ML) HPMC 5mg, Vit A 10.000 IU,Oxymethazoline
244 Asthenof (MD) 0.25mg
245 Augentonic (15ML)
Zinc Sulfat 0.2 mg, Vit A 10.000 IU
246 Augentonic (MD)
247 ALEGYSAL Pemirolast Potassium 0.1%
248 Bralifex Plus Tobramycin 3mg, Dexamethason 1mg
249 Carpine 2% (5ML)
Pilocarpine 20 mg
250 Carpine 2% (MD)
251 Catarlent (15ML) Kalium Iodide 5mg
252 Cenfresh (5ML)
Carboxy Methyl Cellulose, Dextran 70 5mg
253 Cenfresh (MD)
254 Conver 2% (15ML)
Sodium Chromoglycate 20 mg
255 Conver 2% (MD)
256 CRAVIT Levofloxacin 0.5%
257 DIQUAS Diquafosol Sodium 3%
258 EDTA 15ML Ethylen Diamin Tetra Acetate Sodium 4mg
259 Efrisel 10% (5 ML) Phenylepherine HCL 100mg
260 Eyefresh (5ML) Hydroxy Propyl Methyl Cellulose 3mg,
261 Eyefresh (MD) Dextran 70 1mg
Eyefresh Mild (MD) HPMC 2.00 mg/ml, Dextran 70 1.00mg/ml

262
HPMC 2.00 mg/ml, Dextran 70 1.00mg/ml,
Eyefresh Plus (MD) Gliserin 2.00 mg/ml
263
264 Floxa (5ML)
Ofloxacin 3 mg
265 Floxa (MD)
266 Fluoresceine 2% (5ML) Fluorescein Sodium 20mg
267 FLUMETHOLON Fluorometholon 0.1%
268 FLAMAR Diclofenac Sodium 1 mg
269 Giflox (MD) Gatifloxacin 3mg
270 Glaopen (MD) Latanoprost 0.05 mg
271 Glaoplus (MD) Latanoprost 0.05 mg, timolol 5 mg
272 GAFORIN Gatifloxacin 3mg
273 Homatro 2% (5ML) Homatro Hbr 20 mg
Hyalub (MD) Sodium Hyaluronate, Hydroxy Prophyl
274 Methyl Cellulose
275 HIALLID Sod.Hyaluronate 0.1%
276 KARY UNI Pirenoxine 0.005%
277 Lentikular (MD) Pirenoxine 0.05 mg/ml
278 LFX (5ML)
Levofloxacin 5 mg/ml
279 LFX (MD)
280 Lyteers (15ML) Sodium chloride 4.4 mg, Kalium chloride
281 Lyteers (MD) 0.8mg
282 Latipress Latanoprost 0.005%
Hydrocortisone Sod.Phosphate 5mg,
Mycos (5ML)
283 Chloramphenicol 10 mg
284 Mydriatil 1 % (5ML)
Tropicamide 10 mg
285 Mydriatil 1 % (MD)
286 MOLCIN ED 3 ML Moxifloxacin 5mg
287 Natacen (MD) Natamycin 50mg/ml
288 Noncort (5ML)
Diclofenac Sodium 1 mg/ml
289 Noncort (MD)
Sodium Hyaluronat 0.15%, Vit A, Vit E, β-
Navitae
290 Glucan
291 OCUFLAM Fluorometholon 1mg
292 Pantocain 0,5% (5ML) Tetracain HCL 5mg/ml
293 Pantocain 2% (5ML) Tetracain HCL 20mg/ml
294 Patacen (MD) Olopatadine 1mg
295 Polygran (5ML) Polymyxin B Sulfate 10.000 IU, Neomycin
296 Polygran (MD) Sulfate 2.5mg, Gramicidin 0.025mg
297 Polynel (5ml) Fluorometholone 1 mg/ml, Neomycin
298 Polynel (MD) Sulfate 3.5mg/ ml
299 Posop (MD) Fluorometholone 2.5 mg
300 P-Pred (5ML)
Prednisolone Acetat Micronized 10mg/ml
301 P-Pred (MD)
Polyvinylpyroiiodine 20.0 mg/ml, Vitamin A,
Protagenta (MD)
302 Natrium Hyaluronat
Polyethylene glycol 5 mg/ml, Sodium
Siloxan (5ML) Hyaluronate 1.5 mg/ml, Sodium Chloride 50
303 mg/ml
304 Statrol (5ML) Polymyxin B Sulfate 16.250 IU, Neomycin
Sulfate 5 mg, Tetrahydrozolin HCl 0.25
305 Statrol (MD) mg/ml
306 SANBE TEARS Dextran 70 1mg, Hypromellose 3mg
307 Timol 0,25% (5ML)
Timolol Maleate 2.5 mg
308 Timol 0,25% (MD)
309 Timol 0,5% (5ML)
Timolol Maleate 5 mg
310 Timol 0,5% (MD)
311 Tobro (5ML)
Tobramycin 3 mg
312 Tobro (MD)
313 Tobroson (5ML)
Tobramycin 3 mg, Dexamethasone 1 mg/ml
314 Tobroson (MD)
315 Tonor 0,5% (5ML)
Betaxolol HCl 5 mg/ml
316 Tonor 0,5% (MD)
317 Tropine 0.5% (5ML)
Atropine Sulfate 5mg
318 Tropine 0.5% (MD)
319 Tropine 1 % (5ML)
Atropine Sulfate 10mg
320 Tropine 1 % (MD)
321 TAFLOTAN Tafluprost 0.0015%
322 TIM-OPTHAL 0,5% ED Timolol Hydrogen Maleate 5 mg
323 Vasacon (15ML)
Naphazoline HCl 1 mg
324 Vasacon (MD)
325 Vasacon A (15ML) Naphazoline HCl 1mg, Antazoline HCl 2.5
326 Vasacon A (MD) mg/ml
327 Vernacel (5ML) Naphazoline HCL 0.25 mg/ml, Pheniramine
Maleate 3mg
328 Vernacel (MD)
Sodium Iodide 10mg/ml, Potassium Iodide
Vitrolenta (ED 5ml) 5mg/ml, Vitamin A
329
330 Vosama (MD) Betamethasone Sodium Fosfat 1 mg
331 Xitrol (5ML) Dexamethasone Sodium Phospat 1mg,
Neomycin Sulfate 3.5mg/ml, Polymyxin B
332 Xitrol (MD) Sulfate 10.000 IU
333 Cendrid (MD) Idoxuridine 1 mg/ml
334 Cyclon 1% (5ML) Cyclopentolate HCL 10mg/ml
335 IKERVIS MD (0.3ML) Ciclosporin 1mg/ml
336 IZBA ED (2.5ML) Travoprost 30mcg/ml
337 LACOMA ED 2.5ML Latanoprost 0.005%
338 LERGIO ED 3ML Olopatadine 1mg
SIMBRINZA ED (5ML) Brinzolamide 10mg/ml + Brimonidine
339 tartrate 2mg/ml
Sodium Hyaluronat 0.3%,P-Plus (PEG
VISIONLUX PLUS 10ML
340 400),Vit B12
SALEP MATA
Sod hyaluronat, gliserin, babassu oil,

BLEPHASEP carbomer, nipagin, nipasol, aquadest
341
342 Gentamycine 3.5g Gentamycin Sulfate 10mg
343 Hervis Eyeoint Acyclovir 30mg
Hydrocortisone Sod.Phosphate 5mg,
Mycos (E.oint)
344 Chloramphenicol 10 mg
345 Oculenta VD (gel) Vitamin A Palmitate 10 mg
Polygran (E.Oint) Polymyxin B Sulfate 10.000 IU, Neomycin

Sulfate 2.5mg, Gramicidin 0.025mg
346
Tobroson (E.Oint) Tobramycin 3 mg, Dexamethasone 1 mg/ml
347
Dexamethasone Sodium Phospat 1mg,
Xitrol (E.Oint 3.5g) Neomycin Sulfate 3.5mg/ml, Polymyxin B
348 Sulfate 10.000 IU
SYRUP
349 AMOXICILLIN 125 MG / 5 ML DS 60 ML AMOXICILLIN 125 MG / 5 ML
350 ALLORIS SYR Loratadine syr
351 AMOXAN DRY SYRUP Amoxicillin 125 mg/5 ml
352 BUFFECT SUSP 60 Ibuprofen
353 CEFIXIME DRY SYRUP CEFIXIME
354 CEFILA DRY SYRUP Cefixime 100 mg/5 ml
355 DESDIN SYRUP Desloratadine 2,5 mg/5 ml
356 INTRIZIN SIRUP 60 ML/BOTOL Cetirizine
357 NEUVIS PRO SYRUP CITICOLINE 500MG
LUTEIN, LYOCOPENE, EKSTRAK BILLBERRY,
OPTIMAX PLUS SYRUP VIT E, VIT C, ZINC, B-CAROTENE,
358 ZEAXANTHIN
Billberry dry extract 40 mg, Retinol 800 IU,

OPTALVIT SYRUP Beta karoten 0,25 mg, Vit E 25 mg,
359 Selenium 7,5 mcg, Zinc sulfat 2,5 mg
360 RG CHOLINE SYRUP CITICOLINE 500MG/5ML
361 SANMOL SYR Paracetamol
ECHINACEA PYRPUREA EXTR , ZN
362 IMUNOS SYR
PICOLINATE,SELENIUM
363 LAMESON SUSPENSI Methylprednisolone
364 TIRIZ ORAL DROPS Cetirizine di-HCl 10 mg
TAKASUL
365 ASAM MEFENAMAT 500 MG KAP ASAM MEFENAMAT 500 MG
366 ASAM TRANEKSAMAT 500 MG ASAM TRANEKSAMAT 500 MG
367 AMOXICILLIN 500 MG AMOXICILLIN 500 MG
368 AZITHROMYCIN 500 MG KAPLET AZITHROMYCIN 500 MG
369 ALEGI TABLET Dexamethasone 0,5 mg; dexchlorpheniramin
370 AMOXAN 500 KAPSUL AMOXICILLIN 500 MG
371 ANALSIK Diazepam 2 mg + Metampiron 500 mg
372 BECOM C KAPLET Vitamin B Kopleks + Vitamin C
Bilberry dry extract 40 mg, Retinol 800 IU,

BERRY VISION DISP
Vitamin E 20 mg, Beta-carotene 2,5 mg
373
Bilberry dry extract 80 mg, Retinol 1600 IU,

BERRY VISION TABLET Vitamin E 40 mg, Beta-carotene 5 mg,
374
375 CIPROFLOXACIN 500 MG TABLET CIPROFLOXACIN 500 MG
376 CLINDAMYCIN 300 MG KAPS CLINDAMYCIN 300 MG
377 COTRIMOXAZOLE 480 mg TABLET COTRIMOXAZOLE 480 mg
378 CENDO CHOLINE 500MG CITICOLINE 500MG
CENDO VITAL Betakaroten, Vitamin A asetat, Vitamin E
379
380 CEFIXIME 100 MG KAPSUL CEFIXIME 100 MG
381 CETIRIZINE 10 MG TABLET CETIRIZINE 10 MG
382 CEFILA 100 MG KAPSUL CEFIXIME 100 MG
383 CLAHIRIS TABLET Loratadine 10 mg
384 CRAVOX 500 MG TABLET Levofloxasin 250 mg
385 CATAFLAM 50 MG Kalium Diklofenak 50 mg
386 CATAFLAM DISPERSIBLE 50 mg Kalium Diklofenak 50 mg
387 EFLAGEN 50 Kalium Diklofenak 50 mg
388 GLAUCON Acetazolamide 250 mg
389 GLAUCETA TAB Acetazolamide 250 mg
390 HERCLOV Valacyclovir 500mg
391 ITRACONAZOLE 100 mg ITRACONAZOLE 100 mg
392 ITZOL KAPSUL ITRACONAZOLE 100 mg
393 LORATADINE 10 MG LORATADINE 10 MG
394 LAMESON 4 MG TABLET METHYLPREDNISOLONE 4 MG
397 LAPIBAL 250 KAPSUL Mecobalamine 250 mcg
398 LAPIBAL 500 KAPSUL Mecobalamine 500 mcg
399 METHYLPREDNISOLONE 4 MG TAB METHYLPREDNISOLONE 4 MG
401 METRONIDAZOLE 500 MG TAB METRONIDAZOLE 500 MG
403 MEFINAL 500 KAPLET ASAM MEFENAMAT 500 MG
404 NEUROSANBE TAB Vit Neurotropik
405 NEUROSANBE PLUS TAB Vit Neurotropik Methampyron
406 PLASMINEX 500MG TAB ASAM TRANEXAMAT 500MG
LUTEIN, LYOCOPENE, EKSTRAK BILLBERRY,

OPTIMAX
VIT E, VIT C, ZINC, B-CAROTENE
407
OPTIMAX FOR G MIRTOSELECT 31.6%, PYCNOGENOL 63.4%
408
409 OPTIMAX O3 OMEGA 3, LUTEIN, LYCOPENE
410 OMEPRAZOLE 20 MG OMEPRAZOLE 20 MG
Billberry extract, lutein, beta caroten, vit A,
OCULEX CAPS
411 vit E, vit B2
Billberry dry extract 80 mg, Retinol 1600 IU,

Beta karoten 5 mg, Vit E 50 mg, Lutein 250
OPTALVIT PLUS TABLET
mcg, Zeaxanthine 67 mcg, Selenium 15
mcg, Zinc sulfat 5 mg
412
413 RANITIDINE HCL RANITIDINE HCL
414 RG CHOLINE TABLET CITICOLINE 1000MG
Beta-carotene 0,6 mg, Vitamin C 200 mg,
RETIVIT CAPLET 100'S Vitamin E 60 mg, Zn 10 mg, Se 55 mcg, Cu
415 1,5 mg, Lutein 2 mg
Beta-carotene 5 mg, Vitamin C 100 mg,
RETIVIT PLUS CAPLET 100'S Vitamin E 60 mg, Zn 10 mg, Se 55 mcg, Cu
1,5 mg, Lutein ester 30 mg, Lycopene 2 mg,
Zeaxanthin 0,67 mg
416
417 SANMOL TAB Paracetamol 500mg
418 SANPRIMA FORTE Ko-Trimoksazol Forte
419 SICLIDON 100 CEFIXIME 100 MG
420 SPORETIK 100 CEFIXIME 100 MG
421 CENDO CHOLINE Citicoline 1000 mg
422 NEUVIS PRO 1000 Citicoline 1000 mg
423 NUTRI EYE LUTEIN 5MG, ZEAANTIN 1MG, BILBERY EXT
424 TIRIZ KAPLET Cetirizine di-HCl 10 mg
RAPID ANTIGEN
425 Antigen YHLO Rapid Test Swab Antigent Covid-19
426 Antigen Panbio Rapid Test Swab Antigent Covid-19
427 Antigen SD Biosensor Rapid Test Swab Antigent Covid-19
T FORMULARIUM 2021
HARGA BELI
SEDIAAN FARMASI
DISTRIBUTOR
CAIRAN INHALASI KALBE FARMA 1,633,500
CAIRAN IRIGASI MEDEQ MANDIRI UTAMA 165,000
SANBE INFUS 61,185
CAIRAN INFUS
SANBE INFUS
CAIRAN INFUS 76,181

CAIRAN INFUS SANBE INFUS 21,005
SANBE INFUS
CAIRAN INFUS 21,423
SANBE INFUS 21,214

CAIRAN INFUS
SANBE INFUS
CAIRAN INFUS 88,721
SANBE INFUS 21,527

CAIRAN INFUS
SANBE INFUS 23,095
CAIRAN INFUS
SANBE INFUS
CAIRAN INFUS 20,534
108,680
CAIRAN INFUS KALBE FARMA
SANBE INFUS 110,044
CAIRAN INFUS
CAIRAN INHALASI KALBE FARMA 2,673,000
SANBE INFUS 39,600
CAIRAN INFUS
SANBE INFUS
CAIRAN INFUS 10,460
SANBE INFUS 10,405

CAIRAN INFUS
SANBE INFUS 8,600
CAIRAN INFUS
SANBE INFUS 8,800

CAIRAN INFUS
SANBE INFUS
CAIRAN INFUS 7,630
HARGA BELI
SEDIAAN FARMASI
DISTRIBUTOR
ALKES PT MENSA BINA SUKSES 71,225
ALKES OPTHALINDO JAYA 194,100
ALKES OPTHALINDO JAYA 2,482,680
HARGA BELI
SEDIAAN FARMASI
DISTRIBUTOR
BHP PT.ANUGERAH PHARMINDO LESTARI
323,697
BHP PT MENSA BINA SUKSES 1,673,760
BHP PT MENSA BINA SUKSES 841,500
BHP PT. INTI SUMBER HASIL SEMPURNA GLOBAL

5,038
BHP PT. INTI SUMBER HASIL SEMPURNA GLOBAL 42,350
188
426,000
42,350
46,200
338,800
39,600
45,100
BHP MEDEQ MANDIRI UTAMA 396,000

BHP AFINA SINAR CEMERLANG 2,783,000
BHP PT. INTI SUMBER HASIL SEMPURNA GLOBAL 226
BHP AFINA SINAR CEMERLANG 146,667
BHP PT.ANUGERAH PHARMINDO LESTARI 11,660
BHP ANUGERAH SINAR MAHDYANTA 3,850,000
BHP PT.SURYA TAMA MEDIKA 408,375
BHP MURNI PUTRA 38,500
BHP OPTHALINDO JAYA 59,520
BHP OPTHALINDO JAYA 59,520
BHP MEDEQ MANDIRI UTAMA 1,980,000
BHP PT. PANCARAYA 9,946,200
BHP PT. PANCARAYA 433,180
1,562
1,217
BHP PT. KATAMATA OPTOMEDIK 3,080,000
BHP PT. KATAMATA OPTOMEDIK US$ 1,500

BHP PT.ANUGERAH PHARMINDO LESTARI 495
1,430
1,430
8,470

9,570
2,035
2,002

BHP GAMA JAN MUKTI 2,420,000
BHP PT. SUPERTONE 1,089
BHP KALBE
75,240
HARGA BELI
SEDIAAN FARMASI
DISTRIBUTOR
INJEKSI SANBE ETHICA 80,152
INJEKSI NOVELL 6,930
INJEKSI BERNOFARM 11,000
INJEKSI LAPI 219,450
INJEKSI KALBE FARMA 44,000
INJEKSI BAYER 8,312,067
INJEKSI LAPI 41,800
INJEKSI NOVARTIS 3,836,499
INJEKSI INTERBAT 15,249
HARGA BELI
SEDIAAN FARMASI
DISTRIBUTOR
IOL PT MENSA BINA SUKSES 1,916,750
IOL PT MENSA BINA SUKSES 56,100
IOL MEDEQ MANDIRI UTAMA 385,000
IOL AFINA SINAR CEMERLANG 360,800
IOL KARYA PUTRA ANDALAN 220,000

IOL PT. PANCARAYA 810,700
1,410,750
IOL KALBE FARMA
1,848,000
IOL KALBE FARMA
1,980,000
IOL KALBE FARMA
IOL GAMA JAN MUKTI 181,502
AFINA SINAR CEMERLANG 1,425,600

IOL
IOL
IOL
IOL ELOKARSA UTAMA 5,610,000
IOL MEDEQ MANDIRI UTAMA 385,000
IOL
IOL KALBE FARMA 10,890,000

IOL
IOL AFINA SINAR CEMERLANG 2,643,750

IOL

IOL PT. KHASANAH ALKESINDO 2,707,760
HARGA BELI
SEDIAAN VENDOR/DISTRIBUTOR
DISTRIBUTOR
TETES MATA CENDO 10,890.00
TETES MATA FERRON 90,862.75
TETES MATA SANBE VISION 41,897.90
TETES MATA MEIJI 112,069.60
29,645.00
TETES MATA CENDO
33,759.00
TETES MATA CENDO
55,176.00
TETES MATA CENDO
TETES MATA KALBE FARMA 171,270.00
19,239.00
TETES MATA CENDO
136,125.00
TETES MATA KALBE FARMA
34,727.00
TETES MATA CENDO
51,062.97
TETES MATA CENDO
31,702.00
TETES MATA CENDO
TETES MATA NOVARTIS 344,850.00
TETES MATA NOVARTIS 323,950.00

136,125.00
TETES MATA KALBE FARMA
HARGA BELI
DISTRIBUTOR
99,000.00
SALEP MATA KALBE FARMA
SALEP MATA CENDO 35,211.00
25,410.00
SALEP MATA CENDO
17,908.00
SALEP MATA CENDO
41,866.00
SALEP MATA CENDO
34,727.00
SALEP MATA CENDO
HARGA BELI
DISTRIBUTOR
SYRUP HEXAPHARM 5,225.00
SYRUP SANBE ETHICA 56,325.50
SYRUP BERNOFARM 25,410.00
SYRUP LAPI 86,735.00
SYRUP INTERBAT 55,440.00
SYRUP FERRON 101,750.00
71,225.00
SYRUP FERRON
62,700.00
SYRUP LAPI
SYRUP KALBE FARMA 118,800.00

HARGA BELI
DISTRIBUTOR
TAKASUL BERNOFARM 237.60
TAKASUL BERNOFARM 1,584.00
TAKASUL HEXAPHARM 314.50
TAKASUL HEXAPHARM 6,000.39
TAKASUL LAPI 1,410.75
TAKASUL SANBE ETHICA 3,239.50
2,010.25
TAKASUL SANBE VISION
2,945.25
TAKASUL CENDO 7,425.00
2,970.00
TAKASUL CENDO
TAKASUL NOVARTIS 5,454.96
TAKASUL NOVARTIS 5,317.96
TAKASUL SANBE VISION 2,765.62
FERRON 6,274.58
TAKASUL
FERRON 8,750.50
TAKASUL
TAKASUL FERRON 7,122.50
INTERBAT 6,545.00
TAKASUL
5,747.50
TAKASUL LAPI
TAKASUL KALBE FARMA 17,490.00
3,571.70
6,512.28

TAKASUL SANBE ETHICA 303.05

TAKASUL FERRON 40,700.00
TAKASUL KALBE FARMA 7,260.00
HARGA BELI
DISTRIBUTOR
RAPID ANTIGEN SETIA ANUGRAH MEDIKA 55,000
RAPID ANTIGEN KASUMA 124,300
RAPID ANTIGEN KASUMA 121,000
KETERANGAN
TIDAK ADA AKL

KETERANGAN
KETERANGAN
TIDAK ADA AKL
TIDAK ADA AKL
TIDAK ADA AKL
TIDAK ADA AKL

KETERANGAN
KETERANGAN
TIDAK ADA AKL

(Rev 04-03-2021) LAPORAN HASIL RAPAT FORMULARIUM GLOBAL

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(Rev 04-03-2021) LAPORAN HASIL RAPAT FORMULARIUM GLOBAL

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HASIL RAPAT FORMULARIUM

tiap mL mengandung NaCl 0.64%, KCl

Kalium 18 meq. Kalsium 4 meq. Magnesium

Per 1000 mL Na 130 meq, Cl 109 meq, K 4

Tiap 500 mL mengandung Glucose

7 INFUSAN D5+1/4 NS DP Per 1000 mL Na 38.5 meq, Cl 38.5 meq,

Per 1000 mL Na 147 meq, Cl 156 meq, K 4

13 INFUSAN RL DP (500 ML) Per 1000 mL Na 130 meq, Cl 109 meq, K 4

NaCl 0,64%, KCl 0,075%, CaCl2 0,048%,

Sodium Chloride 640mg, Potassium

16 PROANES (20 ml) Propofol 10 mg/ml

Kalium 18 meq. Kalsium 4 meq. Magnesium

Per 1000 mL Na 130 meq, Cl 109 meq, K 4

Tiap 500 mL mengandung Glucose

22 INFUSAN D5+1/4 NS SP BPJS Per 1000 mL Na 38.5 meq, Cl 38.5 meq,

34 1764G - MERSILENE 5/0 S24 DA Braided,synthetic green/undyed (white)

35 23GA CURVED MEMBRAN SCRAPPER Scrapper

43 etil alkohol 70%, deinoze water, carbomer,

113 SAFEGLOVE SURGICAL PF 6; 6,5; 7; 7,5

198 CARTRIDGE D cartridge D

216 SENSAR FOLDABLE IOL WITH OPTIEDGE +6.0 D to +30.0 Diopters

234 TECNIS SYNERGY OPTIBLUE INTRAOCULAR ZFR00V (+5.0 to +34.0)

Preloaded ACRYSOF IQ SN60WF :

IOL MONOFOCAL ASPHERIC NON PRE-

ARTISAN MYOPIA + NEEDLE OPHTEC

Eyefresh Mild (MD) HPMC 2.00 mg/ml, Dextran 70 1.00mg/ml

Sod hyaluronat, gliserin, babassu oil,

Polygran (E.Oint) Polymyxin B Sulfate 10.000 IU, Neomycin

Billberry dry extract 40 mg, Retinol 800 IU,

Bilberry dry extract 40 mg, Retinol 800 IU,

Bilberry dry extract 80 mg, Retinol 1600 IU,

LUTEIN, LYOCOPENE, EKSTRAK BILLBERRY,

Billberry dry extract 80 mg, Retinol 1600 IU,

423 NUTRI EYE LUTEIN 5MG, ZEAANTIN 1MG, BILBERY EXT

424 TIRIZ KAPLET Cetirizine di-HCl 10 mg

CAIRAN IRIGASI MEDEQ MANDIRI UTAMA 165,000

SANBE INFUS 61,185

CAIRAN INFUS 76,181

SANBE INFUS 21,214

SANBE INFUS 21,527

CAIRAN INFUS 20,534

SANBE INFUS 110,044

SANBE INFUS 39,600

CAIRAN INFUS SANBE INFUS 49,250

SANBE INFUS 10,405

SANBE INFUS 8,800

CAIRAN INFUS 7,630

BHP PT. INTI SUMBER HASIL SEMPURNA GLOBAL

BHP MEDEQ MANDIRI UTAMA 82,500

BHP MEDEQ MANDIRI UTAMA 385,000

BHP PT. KATAMATA OPTOMEDIK 4,653,000

BHP PT. INTI SUMBER HASIL SEMPURNA GLOBAL

BHP MEDEQ MANDIRI UTAMA 66,000

BHP MEDEQ MANDIRI UTAMA 44,000

BHP PT. INTI SUMBER HASIL SEMPURNA GLOBAL 12,272

IOL PT MENSA BINA SUKSES 1,262,250

IOL PT MENSA BINA SUKSES 56,100

IOL MEDEQ MANDIRI UTAMA 385,000

IOL AFINA SINAR CEMERLANG 360,800

IOL KARYA PUTRA ANDALAN 220,000

IOL PT MENSA BINA SUKSES 10,098,000

AFINA SINAR CEMERLANG 1,425,600

AFINA SINAR CEMERLANG 5,820,000