Formularium Rs 2019

FORMULARIUM RUMAH SAKIT ISLAM SITI HAJAR MATARAM T
SUB KELAS TERAPI DAN BENTUK

NAMA DAGANG KEMASAN
NAMA GENERIK SEDIAAN
ANALGESIK NARKOTIK
Fentanyl Fentanil Durogesic 12,5 mcg Box 5 patch
Transdermal patch Patch
12,5 mcg/jam
Fentanil Durogesic 25 mcg Box 5 patch
25 mcg/jam
Fentanil Durogesic 50 mcg Box 5 patch
50 mcg/jam
Morfin sulfat Tablet MST Continus 10 mg Box 6 x 10 tab

10 mg Tab
Morfin Sulfat 10 mg Tab
10 mg Tab
Pethidin inj Pethidin inj Clopedin
ANALGESIK NON NARKOTIK DAN ANTIPIRETIK

Asam mefenamat Generik
Asam Mefenamat
Asam mefenamat Mefinal 500 mg Kapl
Tablet 500 mg Box 10 x 10 kapl
Ponsamic 500mg
Ibuprofen Generik
Bufect Tab
Ibuprofen
sirup Bufect Susp
Bufect Forte Susp
Ketorolac TromethamGenerik
Ketorolac Tromethamine ketorolak Larutan Rativol 30 mg Inj

injeksi i.v/i.m 30 Teranol 30 mg Inj
mg/ml Teranol 30 mg tab
Tablet
Metamizole Generik
larutan injeksi Santagesik Inj
Metamizole
tablet Santagesik tab
sirup Santagesik sirup
Paracetamol Generik
Sediaan infus 1000m Sanmol Inf
Suppositoria Pamol 125 mg supp
Pamol 250 mg supp
Paracetamol Pamol 125 mg supp
tablet 500mg Paracetamol
Sanmol tablet
Maganol tablet
tablet 650 Sanmol forte tab
Tramadol HCl
sediaan injeksi
Tramadol HCl Tradosik inj
tablet Tradosik Tab
Kombinasi : metampiron 500mg Kombinasi metampiron 500mg dan diazepam 2mg

dan diazepam 2mg Tablet Analsik Tab
Kombinasi Paracetamol 500mg Kombinasi Paracetamol 500mg dan N-acetylcystein 200mg

dan N-acetylcystein 200mg Tablet Sistenol Tab
Kombinasi tramadol HCl 3,75mg dan paracetamol 325mg

Kombinasi tramadol HCl 3,75mg Tracedol
dan paracetamol 325mg Tablet
Patral Tab Mahakam Beta Farma
Eterocoxib
Orinox 60 mg
Etorvell 60 mg
Eterocoxib Orinox 90 mg
Tablet
Etorvell 90 mg
Orinox 120 mg
Orinox 120 mg
ANTIINFLAMASI NON STEROID

Dexketoprofen tromethamol
Tablet Keren Tab
Dexketoprofen tromethamol
Injeksi Keren Inj
Kalium Diklofenak
Kalium Diklofenak Eflagen 50 mg Tab
Tablet
Kalium Diklofenak
Tablet
Eflagen 25 mg Tab
Ketoprofen
Pronalges 100mg Tab
Tablet 100mg
Kaltrofen 100 mg Tab
Ketoprofen Tablet 50mg Kaltrofen 50 mg Tab
Pronalges Supp
Kaltrofen Supp
Suppositoria
Ketoprofen
Meloxicam
Artrilox 7,5 mg Tab
Ostelox 7,5 mg Tab
Tablet 7,5 mg
Nucoxi 7,5 mg tab
Meloxicam
Velcox 7,5 mg tab
Ostelox 15 mg Tab
Tablet 15 mg Nucoxi 15 mg tab
Velcox 15 mg tab
Natrium Diklofenak
Natrium Diklofenak Tablet 50mg Flamar 50 mg Tab
Tablet 50mg Flamar 25 mg Tab
Piroxicam
Piroxicam Tablet 10mg
Tablet 10mg
ANTIPIRAI
Allopurinol
Tablet 300mg Alluric 300mg
Allopurinol Puricemia 300 mg Tab
Benoxuric 300mg Tab
Etoricoxib
Tablet 60mg Orinox 60mg

Etorvel 60mg
Etoricoxib
Tablet 90mg Orinox 90mg
Etorvel 90mg
Etoricoxib
Orinox 120mg
Etorvel 120mg
OBAT UNTUK PROSEDUR PRE OPERATIF
Diazepam
Sediaan injeksi Valisanbe Inj
Valisanbe 5mg tab
Tablet 5 mg
Diazepam
Tablet 2 mg Valisanbe 2mg tab
Midazolam
Midazolam Fortanest 5 mg Inj
Sediaan injeksi
Sedacum
ANESTESI LOKAL DAN UMUM
Ketamine HCl
Ketamine HCl
Sediaan injeksi KTM 100 mg Inj
Propofol
Propofol Sediaan injeksi Propofol Lipuro Inj
Recofol Inj
Sevoflurane
Sediaan injeksi Sevoflurane inj
Sevoflurane
Sevodex
Soujoure
ANTIALERGI DAN OBAT ANAFILAKSIS

Cetirizine
Cerini Tab
tablet
Cetirizine Rydian tab
Cerini drop
Cerini sirup
Ciproheptadine
Ciproheptadine
Heptasan Tab
Dexamethasone
Sediaan injeksi Kalmethasone Inj
Dexamethasone
Cortidex inj
Tablet Cortidex Tab
Loratadine
Alloris Tab
Loratadine Tablet
Histapan Tab
Mebhydroline napadisylate
Dextamin Syr
Mebhydroline napadisylate
Tablet
Dextamin Tab
Interhistin Tab
Kombinasi betamethasone Kombinasi betamethasone 0,25mg dan dexchlorpheniramine maleat 2mg

0,25mg dan dexchlorpheniramine Colergis
maleat 2mg Tablet
Celestik
ANTIEPILEPSI DAN ANTIKONVULSI

Carbamazepine
Carbamazepine
Tablet Bamgetol Tab
Clonazepam
Clonazepam
Tablet Riclona tab
Diazepam
Tablet Valisanbe 5 mg Tab
Valisanbe 2 mg Tab
Injeksi Valisanbe injeksi
Diazepam
Stesolid 5mg
Suppositoria
Stesolid 10mg
Fenitoin Na
Injeksi
Fenitoin Na Phenitin injeksi
Tablet Curelenz
Alprazolam
Alganax Tab 0,25mg
Frixitas 0,25
Zypraz 0,25
Alganax Tab 0,5mg
Alprazolam Tablet
Frixitas 0,5 mg
Zypraz 0,5 mg
Alganax Tab 0,1 mg
Alprazolam Tablet
Frixitas 1 mg
Zypraz 1 mg
Lorazepam
Lorazepam
Tablet Ativan 1 mg Tab I
Natrium Valproat
Natrium Valproat Depakote tab
Tablet
Divalpi
Phenobarbital
Phenobarbital Tablet Penthal
Sibithal
ANTINYERI PADA SARAF
Gabapentin
Gabapentin
Tablet Galepsi 300
ANTIBAKTERI
PENISILIN
Amoxicillin
Tablet Amoxsan 500 mg Kaps
Kalmoxillin 500mg Tab
Amoxicillin syr
Amoxicillin sirup Amoxsan Syr
Amoxsan Forte Syr
Amoxicillin drop
Drop
Amoxsan Drops
Injeksi Amoxsan 1 gr Inj
Tablet Sanpicillin 500 mg Kaps

Ampicillin Ampicillin
Injeksi
Sanpicillin 1 gr Inj
Co-amoxiclav
(Amoxicillin,
Clavulanic Acid)
Co-amoxiclav (Amoxicillin,
Claneksi Tab
Clavulanic Acid) Tablet
Clavamox 500 mg Tab
Claneksi Syr
sirup
Claneksi Forte Syr
SEFALOSPORIN
Cefadroxil
Tablet
Cefadroxil
Tablet Cefat 500 mg Kaps
Qcef 500 mg kaps
Cefadroxil Cefadroxil
Cefat 125mg Syr
sirup
Cefat Forte Syr
Qcef 250 syr
Cefazolin
Cefazolin
E-zox inj
Cefepime
Cefepime
Injeksi Ceforim
Cefixime
Sporetik 100 mg Kaps
Tablet
Nucef 100mg
Cefixime
Sporetik 200mg
Cefixime
sirup
Sporetik Syr
Cefoperazone
Cefoperazone Injeksi Bifotik 1 gr Inj
Cefoperazone-Sulbactam
Cefoperazone-Sulbactam
Injeksi Cefobactam inj
Cefotaxime
Cefotaxime Injeksi Goforan Inj
Taxegram 1 gr Inj
Cefpirome
Cefpirome
Injeksi Bactirom 1 gr Inj
Ceftazidime
Ceftazidime Injeksi
Zidifec 1 gr Inj
Ceftriaxone
Ceftriaxone Injeksi Cephaflox 1 gr Inj
Terfacef 1 gr Inj
Cefuroxime
Cefuroxime Anbacim 500 mg Tab
Injeksi
BETA LAKTAM
Meropenem
Merosan 1 gr Inj
Meropenem Injeksi Merem 1 gr Inj
Merosan 0,5 gr Inj
Merem 0,5 gr Inj
TETRASIKLIN
Doxycycline
Doxycycline Siclidon 100 mg Kaps
Tablet
Viadoxin
COTRIMOXAZOLE
Kombinasi Trimethoprim 80mg Kombinasi Trimethoprim 80 mg dan sulfamethoxazole 400 mg

dan sulfamethoxazole 400mg Tablet Sanprima Tab
Sirup Sanprima Syr Btl 60 ml
Kombinasi Trimethoprim 16mg Kombinasi Trimethoprim 160 mg dan sulfamethoxazole 800 mg

dan sulfamethoxazole 800mg Tablet Sanprima Forte Tab
MAKROLIDA
Azithromycin
Azithromycin Injeksi Azithromycin
Tablet Zibramax 500 mg Tab
Clarithromycin
Clarithromycin
Tablet Bicrolid
Erysanbe Syr Erythromycin

Erythromycin sirup
Tablet Erysanbe tablet
KUINOLON
Ciprofloxacin
Ciprofloxacin
Injeksi Ciprofloxacin
Ciprofloxacin
Baquinor Forte Tab

Tablet
Ciflos 500
Levofloxacin
Levocin inf
Injeksi
Lefos 750 mg inf
Lefos 500 mg inf
Levofloxacin Levofloxacin
Levocin 500 mg Tab
Tablet Lefos 500 mg Tab
L-Q 500 mg tab
Ofloxacin
Tablet
Ofloxacin Akilen 200 mg Tab
Tarivid 400mg Tab
Betaflox Mahakam Betafarma
Tetes telinga Tarivid otic
AMINOGLIKOSIDA
Amikasin
Amikasin Injeksi
Mikasin Inj
Gentamicin
Injeksi
Sagestam Inj
Gentamicin Gentamicin
Salep
Sagestam salep kulit
Tetes mata Sagestam tetes mata
KLORAMFENIKOL
Chloramphenicol
Injeksi
Colsancetine 1 gr Inj
Chloramphenicol
Chloramphenicol
Tablet
Colsancetine 500 mg
Kaps
Chloramphenicol
Sirup Colsancetin Syr
Thiamphenicol
Tablet
Biothicol tablet
Thiamphenicol
Biothicol
Biothicol Syr
Forte Syr
Sirup
ANTIBAKTERI GOLONGAN LAIN
Clindamycin
Clindamycin Tablet Prolic 150 mg Kaps
Prolic 300 mg Kaps
Sulfasalazine
Sulfasalazine
Tablet Sulcolon 500 mg Tab
ANTISEPTIK SALURAN KEMIH
Asam Pipemidat
Asam Pipemidat
Tablet Urotractin tab
ANTIVIRUS
Acyclovir
Tablet Acyclovir 400mg
Acyclovir Acyclovir 200mg
Acyclovir
Salep
Acyclovir salep kulit
OBAT UNTUK SALURAN KEMIH DAN PROSTAT
Dutasteride
Dutasteride Tablet
Avodart Tab
Nocel
ANTI TUBERKULOSIS
Ethambutol HCl
Ethambutol HCl
Tablet Ethambutol HCl
Pyrazinamide
Pyrazinamide
Tablet Pyrazinamide
Kombinasi :
a. Rifampicin 150 mg
b. Isoniazid 75 mg Tablet Rifastar
c. Pyrazinamide 400 mg
d. Ethambutol HCl 275 mg
ANTIFUNGI
Injeksi Fluconazole
Fluconazole Fluconazole
Tablet
Govazol Tab
Ketoconazole
Tablet
Formyco Tab
Ketoconazole
Ketoconazole
Salep
Formyco cream
Nystatin
Nymico Drops
Nystatin
Suspensi Nyndia drop
Fustin drop
Kombinasi Metronidazole 500mg, nystatin 100.000 IU

Kombinasi :
a. Metronidazole 500 mg Ovula Trichodazole ovula
b. Nystatin 100.000 IU
ANTIAMUBA DAN ANTIGIARDIASIS
Metronidazole
Tablet
Trichodazole tab
Metronidazole Metronidazole
Injeksi Trichodazole inf
Nulagyl inf
ANTIMIGREN
Flunarizine HCl
Gratizin 10 mg Tab
Flunarizine HCl Unalium 10 mg Tab I
Tablet
Gratizin 5 mg Tab
Unalium 5 mg Tab I
Ergotamin
Ergotamin
Tablet Ergotamin
Kombinasi : ergotamin 1mg, Kombinasi : ergotamin 1mg, kafein 50mg
kafein 50mg Tablet Ericaf
ANTIVERTIGO
Betahistine mesylate
Betahistine mesylate Tablet

Mertigo 6 mg
Mertigo SR
Vertigosan
NOOTROPIK DAN NEUROTONIK
Mecobalamin
Ethygobal 500mcg
Tablet
Megabal 500 mcg
Mecobalamin
Methycobal 500mcg
Ethygobal inj
Injeksi
Lanabal inj
Piracetam
Gotropil 3 gr Inj
Revolan 3 gr Inj
Injeksi
Neurotam 3 gr Inj
Revolan 1 gr Inj
Neurotam 12 gr Infus
Revolan 400 mg Kaps
Piracetam Revolan 800 mg Kaps
Revolan 1200 mg Kaps
Gootropil 1200 mg Kaps
Tablet
Gootropil 800 mg Kaps
Neurotam 400 mg Kaps
Sirup Neurotam Syr
ANTIPARKINSON
Pramipexole
Pramipexole
Tablet Pramipexole
Trihexyphenidil HCl
Trihexyphenidil HCl
Tablet Arkine Tab
Kombinasi levodopa 100mg dan Kombinasi levodopa 100mg dan benserazide 25mg
benserazide 25mg Levazide Tab
Tablet
Leparson Tab
ANTIANEMIA
Asam Folat
Asam Folat Tablet
Folavit Tab
Ferro sulfat
Ferro sulfat
Tablet Ferro sulfat
ANTIKOAGULAN DAN ANTIPLATELET
Asetosal
Asetosal Farmasal 100 mg Tab
Tablet
Aspilet Tab
Cilostazol
Pletaal 50 mg Tab
Cilostazol Pletaal 100 mg Tab
Tablet
Naletaal 50
Naletaal 100
Clopidogrel
Vaclo Tab
Clopidogrel Tablet CPG Tab
Dabigatran Etexilate
Tablet Dabigatran Etexilate
Dabigatran Etexilate
Fondaparinux
Arixtra Inj Glaxo Smith Kline
Fondaparinux
Injeksi
Diviti
Warfarin Na
Warfarin Na
Tablet Simarc-2 Tab
ANTI HEMOROID
Kombinasi Diosmim 450mg dan Kombinasi Diosmim 450mg dan hesperidin 50mg
hesperidin 50mg Anadium Tab
Hidrosmin 200mg
Hidrosmin 200mg Tablet Venosmil tab
Gel Venosmil gel
Lesitin murni
Lesitin murni
Tablet Lanaven tab
Esktrak akar litospermi 0,09, etil

amino benzoat 10mg, dibukain
hidroklorida 0,25, Supp Boraginol -N supp
diphenhidramin 0,25setrimid
1,25mg
Ekstrak akar litospermi 0,1mg,

prednisolon 0,5mg , lidokain
7,5mg , etil amino benzoat 10mg, Supp Boraginol - S supp
setrimid 1,25, lesitin telor 50mg
HEMOSTATIK
Asam Traneksamat
Tablet
Plasminex 500 mg Tab
Asam Traneksamat
Kalnex 500 mg Tab
Asam Traneksamat
Injeksi Plasminex 500 mg Inj
Kalnex 500 mg Inj
Carbazochrome
Carbazochrome
Injeksi Crome Inj
Adona AC - 17 Inj
Phytomenadione
Phytomenadione Phytomenadione
Injeksi
Vitadion
Somatostatin
Somatostatin
Somatostatin Somatostatin Lyomark
Injeksi
Inj
OBAT HEMATOPOIETIK
Epoetin α
Hemapo 3.000 IU Inj
Epoetin α
Injeksi
Hemapo 10.000 IU Inj
Eprex 4000 IU Inj
PENGGANTI PLASMA DAN PLASMA EXPANDER
Human Albumin
Biotest 20% 100ml
Biotest 20% 50 ml
Human Albumin
Infus Albumin Behring 20%
100 ml
Albuminar 25% 100 ml
Octalbin 20% 100ml
Octalbin 25% 100ml
DIURETIK
Furosemide
Furosemide
Injeksi Farsix Inj
Furosemide Uresix Inj
Furosemide
Tablet Farsix 40 mg Tab
Uresix 40 mg Tab
Spironolactone
Spironolactone 100mg
Spironolactone
Tablet
Spironolactone 25mg
Spirola Tab
ANTIDIABETES ORAL
Acarbose
Acarbose
Acarbose Tablet
Eclid 50 mg Tab
Gliclazide
Gliclazide
Tablet Diamicron MR
Glimepiride
Glimepiride 1mg
Anpiride 1 mg Tab
Gluvas 1 mg Tab
Glimepiride 2mg
Anpiride 2 mg Tab
Gluvas 2 mg Tab
Metrix 2 mg Tab
Glimepiride Tablet
Pymaril 2mg tab
Glimepiride 3mg
Anpiride 3 mg Tab
Gluvas 3 mg Tab
Glimepiride 4mg
Anpiride 4 mg Tab
Gluvas 4 mg Tab
Gliquidone
Gliquidone
Tablet Glurenorm
Metformin
Metformin
Metformin Forbetes 500 mg Tab
Tablet
Forbetes 850 mg Tab
Benoformin 500
Pioglitazone
Pioglitazone 15mg
Pioglitazone Pioglitazone 30mg
Gliabetes 15mg
Tablet
Gliabetes 30mg
Deculin 15 mg Tab
Deculin 30 mg Tab
HORMON ESTROGEN
Ethinylestradiol
Ethinylestradiol Ethinylestradiol
Tablet
Diane 35 Tab
HORMON PROGESTERON
Allylestrenol
Allylestrenol Progeston Tab
Tablet
Preabor
Norethisterone
Norethisterone Norestil
Tablet
Regumen Tab
INDUKTOR OVULASI
Clomifen Citrate
Clomifen Citrate Blesifen Tab
Tablet
Profertil
KORTIKOSTEROID
Dexamethasone
Dexamethasone
Dexamethasone
Injeksi Cortidex Inj
Tablet Cortidex Tab
Methylprednisolone 125mg inj

Injeksi Steniral 125mg inj
Injeksi
Sanexon 125 mg Inj
Methylprednisolone 16mg
Steniral 16 mg tab
Sanexon 16 mg Tab
Methylprednisolone
Tablet Sanexon 8 mg Tab
Steniral 8 mg tab
Sanexon 4 mg Tab
Steniral 4 mg tab
Triamcinolone acetonide
Flamicort 10mg
Flamicort 40mg
Triamcinolone acetonide Injeksi
Trilac 10mg
Trilac 40mg
Tablet Rafacort
ANTIANGINA
Diltiazem
Diltiazem Tablet Diltiazem
Isosorbide Dinitrate
Tablet Farsorbid 5 mg Tab
Farsorbid 10 mg Tab
Injeksi Isosorbide Dinitrate
Farsorbid Inj
ANTIARITMIA
Amiodarone
Amiodarone Amiodarone
Injeksi
Tiaryt Inj
Tablet Tiaryt 200 mg Tab
Propranolol
Propranolol Propranolol 10mg

Tablet
Propranolol 40mg
ANTIHIPERTENSI
Amlodipine besylate
Amlodipine besylate 5mg
Tensivask 5 mg Tab
Cardisan 5 mg Tab
Lovask 5 mg Tab
Amlodipine besylate
Lopiten 5 mg Tab
Tablet
Amlodipine besylate 10mg
Tensivask 10 mg Tab
Cardisan 10 mg Tab
Lovask 10 mg Tab
Bisoprolol Fumarate
Bisoprolol Fumarate Bisoprolol Fumarate
Tablet
Beta one
Candesartan
Candesartan 16
Canderin 16 mg Tab
Candesartan Candepress 16
Tablet
Candesartan 8
Canderin 8 mg Tab
Candepress 8
Captopril
Captopril 12,5mg
Tensicap 12,5 mg Tab
Captopril
Tablet Captopril 25mg
Tensicap 25 mg Tab
Captopril 50mg
Lisinopril
Lisinopril 5 mg
Lisinopril Tensinop 5 mg Tab
Tablet
Lisinopril 10 mg
Tensinop 10 mg Tab
Nicardipine
Nicardipine Injeksi Perdipine 2 mg Inj
Nifedipine
Nifedipine Nifedipine
Tablet
Farmalat Tab
OBAT SYOK KARDIOGENIK
Dobutamine
Dobutamine
Injeksin 50 mg Dominic Inj
Dopamine
Dopamine Dopac Inj
Injeksi
Dopamin Giulini
Norepinephrine
Norepinephrine
Norepinephrine
Injeksi Vascon
Raivas
VASODILATOR PERIFER DAN AKTIVATOR SEREBRAL
Citicoline 250 mg inj

Beclov 250 mg Inj
Nucholin 250 mg
Injeksi Brainact 250 mg Inj
Citicoline Citicoline 500mg inj
Nucholin 500 mg
Brainact 500 mg Inj
Citicoline 500 mg tab
Tablet
Brainact tab
Isoxsuprine HCl
Isoxsuprine HCl
Tablet Hystolan Tab
ANTIHIPERLIPIDEMIA
Atorvastatin
Atorvastatin 10mg
Atorvastatin
Tablet
Fastor 10 mg Tab
Stator 10 mg Tab
Atorvastatin 20mg
Fastor 10 mg Tab
Stator 20 mg Tab
Fenofibrate
Fenofibrate
Fenofibrate
Tablet
Evothyl Tab
Gemfibrozil
Gemfibrozil Gemfibrozil
Tablet
Hypofil 300 mg Kaps
Rosuvastatin
Rosuvastatin 10
Rosuvastatin
Tablet
Rovator
Simvastatin
Simvastatin
Valemia 10 mg
Simvastatin
Tablet Simvastatin
Valemia 20 mg
Cholestat 10 mg Tab
ANTIBAKTERI KULIT
Asam Fusidat
Asam Fusidat Fuladic cream
KORTIKOSTEROID TOPIKAL
Momethasone furoate
Momethasone furoate Mefurosan Krim
Cream
Elox Krim
ANTIFUNGI TOPIKAL DENGAN KORTIKOSTEROID
Kombinasi (per gram krim) :

Cream Thecort Krim
a. Miconazole nitrate 20 mg
b. Hydrocortisone 10 mg
ANTIFUNGI DAN ANTIPARASIT TOPIKAL

Ketoconazole
Ketoconazole
Ketoconazole
Cream Formyco Krim
Mycoral Krim
PREPARAT MULUT/TENGGOROKAN
Kombinasi :
Tube 8 ml
a. Na hyaluronate, glycyrrhetic
acid, maltodextrin
b. Hydrogenated castor oil,

disodium edetate, aqua
gel Aloclair Plus Gel
c. Benzalkonium klorida,
saccharin Na, Na benzoate
d. Hydroxyethylcellulose, PEG
40, K sorbate
e. Aloe vera extract, propylene
glycol, PVP
SEDIAAN ELEKTROLIT DAN NUTRISI
Tutofusin OPS Inf

Kombinai (per liter larutan) :
a. Natrium 30 mEq, chloride 20 Triofusin Inf
mEq Cairan
b. Lactate 10 mEq, glucose 40 Clinimix Infus
gram
Kombinasi (per liter larutan) : Widahes 200

a. HES 200.000/0,5 60 gram,
NaCl 6,9 gram Sanbehes 200
Cairan
b. KCl 0,3 gram, CaCl2 0,22
gram Fima HES 200 Inf
c. Larutan Na lactate 4,48%
Kombinasi (per liter larutan) :

a. Na 100 mEq, K 18 mEq, Ca 4 Aminofluid 500 mg Inf
mEq Cairan
Cairan
b. Mg 6 mEq, Cl 90 mEq, acetate Aminofluid 1000 mg Inf
38 mEq
c. Sorbitol 50 gram
OKSITOSIK
Methylergometrine
Methylergometrine inj
Methylergometrine Injeksi
Bledstop inj
Tablet Bledstop tab
Oksitosin
Oksitosin
Injeksi Santocyn
RELAKSAN UTERUS
Misoprostol
Misoprostol
Tablet Gastrul Tab
ANTIANSIETAS DAN ANTIINSOMNIA
Clobazam
Clobazam
Tablet
Clobazam Clofritis tab
Zolpidem
Zolpidem Zudem
Tablet
Zolta
ANTIDEPRESI DAN ANTIMANIA
Fluoxetine
Fluoxetine 10 mg
Nopress 10mg
Fluoxetine Kalxentin 10mg
Tablet
Fluoxetine
Nopress 10mg
Kalxentin 10mg
Maprotilline HCl
Maprotilline HCl
Tablet
Sandepril 50 mg Tab
Sertraline
Sertraline
Sertraline
Tablet Nudep
Sernade
ANTIPSIKOSIS
Haloperidol
Haloperidol
Govotil 2 mg Tab
Haloperidol Tablet
Govotil 5 mg Tab
Injeksi Lodomer Inj
Risperidone
Risperidone 1mg
Rizodal 1mg
Risperidone Risperidone 2mg
Tablet
Rizodal 2 mg
Risperidone 3mg
Rizodal 3 mg
Aripriprazole
Aripriprazole Arinia 10mg
Tablet
Zipren 10mg
Chlorpromazin
Chlorpromazin 100mg
Chlorpromazin Tablet
CPZ tab 100mg
Injeksi CPZ Inj
Clozapin
Clozapin
Clozapin Nuzip 100
Tablet
Clorilex 100
Nuzip 25
Olanzapine
Olanzapine
Olanzapine
Tablet Remital
Sopavel
Quetiapin
Quetiapin Quetiapin
Tablet
Quetvell
RELAKSAN OTOT PERIFER
Atracurium besylate Injeksi Atracurium - Hameln 25 mg

Atracurium - Hameln 50 mg
Tramus 25
Tramus 50
Eperisone HCl
Eperisone HCl Tablet Forelax
Eprinoc Tab
Myonal
Rocuronium Bromide
Rocuronium Bromide Injeksi Rocum
ANTASIDA DAN ANTIULKUS
Lansoprazole
Lansoprazole Kapsul Lansoprazole
Lapraz Kaps
Lasgan Kaps
Prazotec Kaps
Pysolan Kaps
Omeprazole
Omeprazole inj
Injeksi Pumpitor Inj
Omeprazole Norsec inj Guardian Pharmatama
Pumpitor Kaps
Kapsul Norsec Kaps Guardian Pharmatama
Priloz Kaps
Pantoprazole
Pantoprazole inj
Injeksi
Pantoprazole Pumpicel inj
Kapsul Pantoprazole Kaps
Ranitidine
Ranitidine inj Box 5 amp @ 2 ml
Injeksi Acran inj
Ranitidine HCl Rantin Inj
Ranitidine tab
Tablet Acran tab
Rantin tab
Sucralfate
Sucralfate sirup
Episan sirup
Sucralfate Sirup
Inpepsa sirup Fahrenheit Farma
Nucral sirup
Tablet Nucral tab
Kombinasi (per 5 ml suspensi) Kombinasi (per 5 ml suspensi) aluminium hidroksi 200mg, magnesium hidroksida
aluminium hidroksi 200mg, Sirup Antasida sirup 200mg
magnesium hidroksida 200mg Plantacid sirup
Tablet Antasida tab
Aluminium hydroxide,
Magnesium carbonate, Calcium
carbonate Co-precipitate 244 mg Tablet Stomacain Tab
Kombinasi (per 5 ml suspensi) : Btl 120 ml
a. Magnesium trisilicate 325 mg

Suspensi Sanmag Susp
b. Aluminium hydroxide 325 mg
c. Simethicone (activated
dimethicone) 25 mg
ANTIEMETIK
Domperidone
Domperidon sir
Sirup Vometa Drops
Vometa sir
Domperidone Vosedon sir
Domperidon Tab
Vometa tab
Tablet
Vosedon tab
Galflux tab Guardian Pharmatama
Metoclopramide HCl
Metoclopramide HCl
inj
Injeksi
Damaben inj
Metoclopramide HCl
Metoclopramide HCl
Metoclopramide HCl
tab
Tablet
Damaben tab
Ondansetron
Ondansentron 4 mg inj
Ondansentron 8 mg inj
Ondane 4 mg Inj Guardian Pharmatama
Injeksi
Ondane 8 mg Inj Guardian Pharmatama
Trovensis 4 mg Inj
Ondansetron Trovensis 8 mg Inj
Ondansentron 4 mg tab
Ondansentron 8 mg tab
Trovensis 4 mg tab
Tablet
Trovensis 8 mg tab
Vomceran 4 mg tab
Vomceran 4 mg tab
ANTISPASMODIK
Hyoscine N-butylbromide
Hyoscine N-butylbromide Injeksi Gitas inj
Tablet Scobutrin tab
Rebamipide
Rebamipide Tablet Mucosta Tab
Sysmuco Tab
Kombinasi hyoscine N- Kombinasi hyoscine N-butylbromide 10mg, paracetamol 500mg

butylbromide 10mg, paracetamol Gitas plus tab
500mg Tablet
Scopamin plus tab
Kombinasi Chlordiazepoxide Kombinasi Chlordiazepoxide 5mg, clidium bromide 2,5mg

5mg, clidium bromide 2,5mg Tablet Braxidin Tab
LAKSATIF
Bisacodil
Suppositoria Dulcolax supp 5 mg
Bisacodil Dulcolax supp 10 mg
Tablet Dulcolax 10mg tab
Lactulosa
Lactulosa
Lactulosa Opilax sir
Sirup
Lactulax sir
Kombinasi :
a. Monobasic Na phosphate 19 gr
Fleet Enema
b. Dibasic Na phosphate 7 gram
Kombinasi :
a. Monobasic Na phosphate 2,4 gr
Fleet Phosphosoda
b. Dibasic Na phosphate 0,9 gram
KOLAGOGUM, KOLELITOLITIK DAN HEPATOPROTEKTOR
Ursodeoxycholic Acid
Tablet Urdahex tab
Urdex tab
Kombinasi :
a. Glycyrrhizin (JP) 40 mg Stronger Neo-
Injeksi Minophagen C (SNMC)
b. Glycine 400 mg Inj
c. L-cysteine HCl 20 mg
Kombinasi :
a. Lecithin murni 175 mg, vit B1

6 mg, vit B2 6 mg, vit B6 6 mg Tablet Lesichol Kaps
b. Vit B12 6 mcg, vit E 10 mg,

nicotinamide 30 mg
ANTIDIARE
Loperamide
Loperamide HCl Loperamide HCl
Tablet
Lodia Tab
ANTIASMA
Aminophylline
Aminophylline Injeksi Aminophylline inj
Tablet Aminophylline tab
Procaterol HCl hemihydrate
Procaterol HCl hemihydrate Ataroc 0,025 mg tab
Sirup Ataroc sir
Salbutamol
Salbutamol 2 mg tab
Tablet
Salbutamol Salbutamol 4 mg tab
Astharol 2 mg tab
Astharol 4 mg tab
Injeksi Ventolin inj
Kombinasi : Combivent UDV
a. Ipratropium bromida 0,5 mg Farbivent Nebules

Nebules
b. Salbutamol sulfat 2,5 mg
Kombinasi :
a. Salbutamol sulphate 1 mg Tablet Teosal tab
b. Theophylline 130 mg
Symbicort 160
Kombinasi :
Turbuhaler 60 Dosis
Turbuhaler
a. Budesonide 160 mcg Symbicort 160
b. Formoterol fumarate 4,5 mcg Turbuhaler 120 Dosis
Kombinasi
Seretide Diskus 100
a. Salmeterol 50 mcg Glax 100 mcg/puff inh
60 dosis
Seretide Diskus 250
Glax 250 mcg/puff inh
b. Flutikason propionat 60 dosis
Inhaler
Inhaler
Seretide Diskus 500
Glax 500 mcg/puff
Seretide Inhaler 50
Glax 50 mcg/puff
EKSPEKTORAN DAN MUKOLITIK

Ambroxol HCl
Tablet Ambroxol HCl
Epexol tab
Extropect tab Guardian Pharmatama
Ambroxol HCl
Sirup Ambroxol HCl
Epexol sir
Epexol drop
Extropect sir Guardian Pharmatama
Bromhexine
Tablet Mucohexine tab
Bromhexine
Sirup Mucohexine sirup
N-acetylcysteine
N-acetylcysteine N-acetylcysteine
Tablet
Sistenol tab
ANTIINFLUENZA DAN ANTIALERGI
Kombinasi : Aldisa-SR Kaps
a. Loratadine 5 mg Kapsul Rhinos SR Kaps

b. Pseudoephedrine sulphate 120
mg
Kombinasi : Tremenza tab

Tablet
b. Triprolidine HCl 2,5 mg Rhinofed tab
OBAT BATUK DAN PILEK
Kombinasi : Box 25 x 4 kapl

a. Dekstrometorfan HBr 10 mg
b. Fenilpropanolamin HCl 15 mg Tablet Tuzalos kaplet
c. Klorfeniramin maleat 1 mg
d. Parasetamol 500 mg
Kombinasi :
a. Codein 30 mg
b. Phenyltoloxamine 3,67 mg
Codipront Cum
Kapsul
Expectorant Kaps
c. Guaiphenesin 55,55 mg
d. Thyme fluid extract 55,55 mg
IMUNOGLOBULIN
Ig tetanus manusia
Ig tetanus manusia Ig tetanus manusia
Injeksi
Tetagam P 250 IU Inj
OBAT YANG MEMPENGARUHI TULANG
Calcitriol
Oscal 0,25 mg
Calcitriol Oscal 0,5 mg
Kapsul
Triocol 0,25 mg
Triocol 0,5 mg
Kombinasi :
a. Glucosamine HCl 500 mg,
chondroitin sulphate 400 mg
Tablet Opus
b. Manganese 0,5 mg,
magnesium 10 mg, Zn 5 mg, vit
C 50 mg
Kombinasi :
a. Glucosamine HCl 250 mg,

chondroitin sulphate 400 mg Vostem effervescent
b. Vit C 100 mg, vit E 10 mg,
manganese 0,25 mg
c. Zn 2,5 mg, Ca 100 mg,
selenium 5 mcg
SUPLEMEN DAN TERAPI PENUNJANG
ekstrak Ophiocephalus striatus Inbumin

Kapsul
(ikan gabus
ekstrak Ophiocephalus striatus
Kapsul
(ikan gabus Vip Albumin
Ekstrak Lumbricus rubellus 490 mg

Ekstrak Lumbricus rubellus 490 Disolf Tab
mg
Lagerstroemia speciosa, Cinnamomum burmannii

Lagerstroemia speciosa, Inlacin 100 mg Tab
Tablet
Cinnamomum burmannii Inlacin 50 mg Tab
Kombinasi :
a. Co-enzyme Q10
(Ubidecarenone) 100 mg
Tablet Tonicard Kaps
b. L-carnitine 500 mg
c. Vit E 100 IU, asam folat 800
mcg
Kombinasi (per 5 ml sirup) :

a. Echinacea purpura 250 mg Nufit Tab
b. Black Elderberry extract 400 Tablet
mg
c. Zinc picolinate 5 mg
Kombinasi :
a. Echinacea purpura extract 250
mg, Phyllantus niruri extract 50
mg Tablet Formuno tab
b. Black Elderberry extract 300
mg, zinc picolinate 10 mg
c. Vit C 100 mg
Kombinasi :
a. Echinacea purpura extract
1000 mg, Phyllantus niruri
extract 50 mg Tablet Formuno Extra Tab Eff
b. Black Elderberry extract 300

mg, zinc picolinate 10 mg
Kombinasi :
a. Tyndallized lyophilisate
Lactobacillus acidophilus 340 mg
Sachet Dialac Sachet

b. Dextrose 322 mg, vegetable
cream powder 45,1 mg
c. Milk calcium 20 mg, bubuk
aroma stroberi 200 mg Sachet Dialac Sachet
d. Bubuk perasa stroberi 40 mg,
niacin 1 mg, Zn oxide 1,3 mg
e. Vit B1 3 mg, riboflavine 0,3

mg, vit B6 0,3 mg, sucrose 1 mg
f. Stevioside 1 mg, ascorbic acid

25 mg
Kombinasi :
a. Placenta extract 15 mg
b. Vit B12 20 mcg, Ca phosphate Tablet Laktafit Tab
dibasic 12 mg
c. Ca phosphate dibasic 12 mg
VITAMIN DAN MINERAL
Calcium
Tablet Calcium
Calcium
Injeksi Cernevit Inj
Fe Elemental
Tablet Maltofer Tab
Fe Elemental
Maltofer Drops
Sirup
Maltofer Syr
Zinc
Zinc Tablet Zinc
Sirup 20mg/5ml Orezink
Kombinasi :
a. Beta carotene 10.000 IU, vit

B1 mononitrate 10 mg, vit B2 2,5
mg
b. Nicotinamide 20 mg, vit B6
HCl 15 mg, Ca panthothenate 7,5
mg
Tablet Folamil genio Tab
Tablet Folamil genio Tab
c. Vit B12 4 mcg, vit C 100 mg,
vit D 400 IU, asam folat 1 mg
d. Potassium iodide 100 mcg,

ferrous fumarate 90 mg, cupric
sulphate 0,1 mg
e. Ca lactate 250 mg, sodium
fluoride 1 mg
Kombinasi :
a. Fe fumarate 360 mg, folic acid
1,5 mg, vit B12 15 mcg Tablet Prenamia Kaps
b. Vit C 75 mg, vit D3 400 IU, Ca
carbonate 200 mg
Kombinasi :
a. Fe fumarate 90 mg, cupric

sulphate 0,35 mg, cobalt sulphate
0,15 mg
b. Manganese sulphate 0,05 mg, Tablet Emineton Tab
vit B6 3 mg, vit B12 5 mcg, vit C
60 mg
c. Vit E 5 mg, folic acid 400 mcg,
Ca phosphate dibasic 60 mg
Kombinasi (per 0,6 ml) :

a. Vit A 5000 IU, vit D 400 IU,
vit C 50 mg
b. Vit B1 1 mg, vit B2 1,2 mg, vit drop San-B-Plex Drops
B6 1 mg
c. Nicotinamide 10 mg,
dexpanthenol 5 mg
Kombinasi :
a. Dibasic Ca phosphate 200 mg,

Ca lactate 100 mg, vit B6 20 mg
Tablet Elkana Tab
b. Vit C 25 mg, vit D3 100 IU
Kombinasi (per 5 ml sirup) :
a. Vit A 2400 IU, vit B1 4 mg, vit
B2 1,2 mg, vit B6 1,2 mg
b. Vit B12 4 mcg, vit C 60 mg,
vit D 400 IU
c. Nicotinamide 16 mg, Ca Sirup Elkana Syr
panthothenate 6 mg
d. Coline 12 mg, inositol 12 mg,
Ca gluconate 300 mg
e. Ca hypophosphite 20 mg, l-
lysine HCl 200 mg
Kombinasi (per 5 ml emulsi) :

a. Vit A 2400 IU, vit D 400 IU,
Cod Liver Oil 8 mg
b. DHA 10 mg, AA 15 mg,
Curcuma extract 12 mg
c. Vit B1 4 mg, vit B2 1,2 mg, vit
B6 1,2 mg Sirup Elkana CL Emulsi
d. Nicotinamide 16 mg, coline 12

mg, inositol 12 mg
e. L-lysine HCl 100 mg, Ca 33,1
mg, Na 5,2 mg, GOS 500 mg
Kombinasi :
a. Retinol 3500 IU,
cholecalciferol 220 IU,
alphatocopherol 11.200 IU
b. Ascorbic acid 125.000 mg,
cocarboxylase tetrahydrate 5800
mg, thiamine 3.510 mg
c. Riboflavine sodium phosphate

dihydrate 5.670 mg, pyridoxine Injeksi Cernevit Inj
hydrochloride 4.530 mg
d. Cyanocobalamine 0,006 mg,
folic acid 0,414 mg,
dexpanthenol 16.150 mg
e. Biotin 0,069 mg, nicotinamide

46.000 mg, glycine 250.000 mg
f. Glycocholic acid 140.000 mg,
soya lecithin 112.500 mg, sodium
hydroxide q.s
Kombinasi :
a. Thiamin HCl 100 mg
Tablet Neurosanbe 5000 Tab
b. Pyridoxine HCl 100 mg
c. Cyanocobalamin 5000 mcg
Kombinasi (per ml larutan) :

a. Thiamin HCl 100 mg
Injeksi Neurosanbe Inj
b. Pyridoxine HCl 100 mg
c. Cyanocobalamin 5000 mcg
Kombinasi :
a. Vit B1 100 mg, vit B6 50 mg,
vit B12 100 mcg, vit E natural Tablet Forneuro Kaps
200 IU
b. Folic acid 400 mcg
Kombinasi :
a. Vit E 30 mg, vit C 750 mg, vit

B1 15 mg, vit B2 15 mg, vit B6
20 mg, vit B12 12 mcg Tablet Becom-Zet Tab
b. Asam folat 400 mcg,

panthothenic acid 20 mg, Zn 22,5
mg, niacin 100 mg
ANTIDIABETES PARENTERAL
Basal insulin analog Insulin glargine
Lantus Solostar pen

Insulin glargine Injeksi
Sansuline inj
Rapid insulin analog Insulin glulisine

Insulin glulisine Injeksi Apidra Solostar Pen
Insulin Lispro
Insulin Lispro Injeksi
Humalog inj
Insulin Detemir
Insulin Detemir Injeksi
Levemir inj
Insulin Aspart
Insulin Aspart Injeksi
Novorapid pen
Mix insulin analog Injeksi

Kombinasi :
Humalog mix inj
a. Insulin lispro 25 %
b. Insulin lispro protamine 75%
TI HAJAR MATARAM TAHUN 2019
BPJS ATAU NON

PRODUSEN BPJS
KETERANGAN
Janssen-Cilag
Non BPJS
Janssen-Cilag
Non BPJS
Janssen-Cilag
Non BPJS
Mahakam Beta
Farma BPJS
Mahakam Beta Hanya untuk pasien
Farma BPJS kanker
Mahakam Beta
Farma BPJS
Hanya untuk pasien

Kimia Farma BPJS
post op
DAN ANTIPIRETIK
Generik
BPJS Maksimal 30tab/bulan
Sanbe Farma Non BPJS
Guardian Non BPJS
Generik BPJS
Maksimal 30tab/bulan
2amp/hari, maksimal
Generik BPJS
2 hari
Guardian Non BPJS
Guardian Non BPJS
Generik BPJS maksimal 4amp
Sanbe Farma BPJS selama dirawat
Generik BPJS
Sanbe Farma BPJS
Interbat Non BPJS
Interbat Non BPJS
Interbat Non BPJS
Generik BPJS
Sanbe Farma BPJS Maksimal 30tab/bulan
Guardian BPJS
Sanbe Farma Non BPJS Maksimal 30tab/bulan
Generik BPJS hanya untuk pasien

Sanbe Farma Non BPJS post op
zepam 2mg Non BPJS

ylcystein 200mg BPJS

Dexa Medica Non BPJS
cetamol 325mg Non BPJS

Nulab Non BPJS
Mahakam Beta Farma Non BPJS
Non BPJS
Dexa medica Non BPJS
Novell Non BPJS
Novell Non BPJS
Novell Non BPJS
N STEROID
Non BPJS
Nulab Non BPJS
Nulab Non BPJS
BPJS
Non BPJS
Dexa Medica
Non BPJS
Kalbe Farma
Non BPJS
Kalbe Farma
Non BPJS
Kalbe Farma Non BPJS
2 supp/hari, maksimal
BPJS
3 hari
BPJS
Combiphar BPJS
Sanbe Farma BPJS
Nulab BPJS
Novell BPJS
Sanbe Farma BPJS
Nulab BPJS
Novell BPJS
BPJS
Non BPJS
Non BPJS
Non BPJS
BPJS
Kalbe Farma BPJS
Sanbe Farma BPJS 30tab/bulan
BPJS
Bernofarm
Non BPJS

Novell Non BPJS
Novell Non BPJS
Novell Non BPJS
PRE OPERATIF
BPJS
Hanya resep dari
Sanbe Farma Non BPJS dokter spesialis
kejiwaan
BPJS
AN UMUM
BPJS
Guardian Non BPJS
BPJS
B'Braun BPJS
Dexa Medica BPJS
BPJS
Abbot Non BPJS
Fahrenheit BPJS
ANAFILAKSIS
BPJS
Guardian Non BPJS
Non BPJS
Generik BPJS
Generik BPJS
Non BPJS
Phapros Non BPJS
Phapros Non BPJS
Interbat Non BPJS
heniramine maleat 2mg Non BPJS

Pyridam Non BPJS
TIKONVULSI
BPJS
Mersi BPJS
BPJS Hanya resep dari

dokter spesialis
Mersipharma BPJS kejiwaan
Generik BPJS Hanya resep dari

dokter spesialis
Sanbe Farma Non BPJS kejiwaan
Sanbe Farma BPJS
BPJS
Actavis
BPJS
Actavis
Generik BPJS
Pyridam Non BPJS
Novell Non BPJS
Generik BPJS
Guardian Non BPJS
Novell Non BPJS
Kalbe Non BPJS Hanya resep dari
Guardian Non BPJS dokter spesialis
Novell Non BPJS kejiwaan
Kalbe Non BPJS
Guardian Non BPJS
dokter spesialis
kejiwaan
Novell Non BPJS

Kalbe Non BPJS
Non BPJS
Sanofi Aventis Non BPJS
BPJS
Abboth BPJS
Kalbe Non BPJS
Generik BPJS
Combiphar Non BPJS
Mersifarma Non BPJS
SARAF
Generik BPJS
30tab/bulan
Guardian Non BPJS
RI
Generik BPJS
Maksimal untuk 10
hari
Generik BPJS
Sanbe Farma Non BPJS Maksimal
Generik BPJS 1botol/kasus

Generik BPJS
Generik BPJS

IN
Generik BPJS
Guardian Non BPJS
Generik BPJS
Guardian Non BPJS
Non BPJS
Nulab Non BPJS
Non BPJS
Sanbe farma Non BPJS
Generik BPJS
Sanbe Farma Non BPJS Maksimal untuk
Guardian Non BPJS pemakaian 3hari
Generik BPJS
Untuk mengatasi
Generik BPJS infeksi pada pasien
Sanbe Farma Non BPJS yang mengalami
fungsi ginjal,, 3gr/hari
selama 7 hari
Non BPJS
Generik BPJS
Guardian Non BPJS Maksimal 10 hari
Non BPJS
3gr/hari selama 7hari,,

Generik BPJS untk bakteri yang
resisten terhadap AB
Sanbe Farma Non BPJS lain (harus
melampirkan hasil lab
resistensi)
Generik BPJS
Guardian Non BPJS 2gr/hari selama 7 hari
Non BPJS
Sanbe Farma
Non BPJS
Generik BPJS
Hanya untuk infeksi
Guardian Non BPJS
kuman ESBL
Guardian Non BPJS
Non BPJS
Pyridam Non BPJS
thoxazole 400 mg BPJS 4 tab/hari selama 10

hari kecuali pada
immunocomprosed
Sanbe Farma Non BPJS selama 21 hari
thoxazole 800 mg Non BPJS 2 tab/hari selama 10

hari kecuali pada
immunocomprosed
selama 21 hari
BPJS
1 vial/hari selama 3
Non BPJS
hari
Guardian Non BPJS 3 tab / kasus
Non BPJS
Non BPJS
BPJS
maksimal 4 btl/hari,
tidak digunakan untuk
BPJS pasien <18 thn dan
ibu hamil

Guardian Non BPJS
Generik BPJS
Sanbe Farma Non BPJS maksimal 10 hari,, tdk
untuk wanita hamil
Guardian Non BPJS dan pasien <18thn
Guardian Non BPJS
Generik BPJS
Guardian Non BPJS
Mahakam
Non BPJS
tidak digunakan untuk

Generik BPJS pasien <18 thn dan
ibu hamil
Mahakam Betafarma Non BPJS
IDA
Generik BPJS Hanya digunakan

untuk infeksi bakteri
Kalbe Farma Non BPJS gram negatif yang
resistesi thd
Generik BPJS
Generik BPJS
KOL
Generik BPJS
Sanbe Farma Non BPJS 3gr/hari selama 14 hari
Generik BPJS 4 kapsul/hari selama

10 hari

Sanbe Farma Non BPJS 1 botol / kasus
Generik BPJS
NGAN LAIN
Generik BPJS
Non BPJS
Bernofarm Non BPJS
AN KEMIH
Non BPJS
Generik BPJS
Generik BPJS
Generik BPJS
Generik BPJS
Generik BPJS
MIH DAN PROSTAT
Generik BPJS
SmithKline Maksimal 30tab/bulan
BPJS
Beecham
Novell Non BPJS
LOSIS
BPJS
Generik BPJS
BPJS
Generik BPJS
Indofarma Non BPJS
Generik BPJS Hanya digunakan

untuk candidiasis
Generik BPJS
sitemik pada pasien
Guardian Non BPJS immunocompromised
Generik BPJS
Maksimal 30tab /
Sanbe Farma BPJS
kasus
Generik BPJS
BPJS 2 btl/kasus untk 1 mggu

Guardian Non BPJS
Mahakam Non BPJS
n 100.000 IU
GIARDIASIS
Generik BPJS Untk infeksi akibat

bakteri anaerob, dapat
diberikan maksimum
Generik BPJS 2 mggu/kasus
Guardian Non BPJS
Non BPJS
Guardian Non BPJS
Guardian Non BPJS
Hanya digunakan
BPJS untuk serangan
Generik BPJS migren akut
n 50mg
Tempo BPJS 8 tab / minggu
Hanya untuk sindrom

Generik BPJS meniere dan vertigo
perifer
UROTONIK
Generik BPJS Maksimal 7 hari

Guardian Non BPJS
Eisei Non BPJS
Guardian Non BPJS
Landson Non BPJS
Generik BPJS
Guardian BPJS
Soho Non BPJS
Guardian Non BPJS
Guardian Non BPJS
ON
Generik BPJS 60 tab / bulan
BPJS
Pyridam Non BPJS
azide 25mg BPJS
Pyridam Non BPJS
Generik BPJS
BPJS
Generik BPJS
NTIPLATELET
BPJS
Fahrenheit BPJS
UAP BPJS
BPJS
Otsuka BPJS
Otsuka BPJS
Guardian Non BPJS
Guardian Non BPJS
Generik BPJS infarc, stroke

iskemik/PAD c)sindrom
Dexa Medica Non BPJS koroner akut NON
Kalbe Farma Non BPJS STEMI dan STEMI
d) hati2 interaksi obat
gol. PPI. Saat tind
PTCA 4-8 tab,
BPJS Utk pencegahan VTE

(Venous Thrombo
Embolism) pada hip dan
Generik BPJS knee replacement,, 30
tab pasca operasi
BPJS Untk tromboemboli

dan sindrom koroner
Glaxo Smith Kline BPJS akut
BPJS Untk pencegahan dan

terapi
Fahrenheit BPJS thromboembolism
OID
ridin 50mg Non BPJS
Guardian Non BPJS
Non BPJS
Kalbe Non BPJS
Kalbe Non BPJS
Non BPJS
Landson Non BPJS
Takeda Non BPJS
Takeda Non BPJS
utk post operasi

Generik BPJS maksimal pemakaian
2 hari
Generik BPJS
Non BPJS
Ferron Non BPJS

Tanabe Non BPJS
BPJS
Generik BPJS
Kalbe Non BPJS
Combiphar Non BPJS
OIETIK
Hanya untuk
penderita CKD
Generik BPJS dengan kriteria
berikut :
a. kadar hb , 10f/dl
Kalbe Farma Non BPJS (terapi awal) dan 10-
12g/dl (terapi
rumatan)
b. kadar besi normal

Kalbe Farma Non BPJS (SI.60mcg/dl) dan
atau indeks saturasi
besi (SI/TIBC x
100%) >20%
Janssen Non BPJS
ASMA EXPANDER
BPJS Kadar albumin <2,5

Kimia Farma BPJS g/dl dan/atau untuk
Kimia Farma BPJS kasus perioperatif dan
atau utk sindrom

Kalbe farma Non BPJS
BPJS
Generik BPJS
Fahrenheit Non BPJS
Fahrenheit Non BPJS
BPJS
BPJS Untuk penyakit sirosis

Generik hepatik 30tab/bln
ORAL
BPJS
90 tab / bulan
Generik BPJS
BPJS
Servier BPJS 30 tab / bulan
BPJS
Pyridam Non BPJS
BPJS
Boehringer BPJS
Generik 90 tab / bulan

Sanbe Farma
Sanbe Farma
Bernofarma
Tidak diberikan pada
pasien gagal jantung
BPJS dan atau riwayat
keluarga bladder
cancer
Sanbe Farma
Non BPJS
Sanbe Farma
Non BPJS

OGEN
BPJS
BPJS
Bayer Non BPJS
TERON
BPJS
Mepro Non BPJS
BPJS Hanya untk amenorea

BPJS sekunder, pendarahan
Non BPJS uterus abnormal dan
Sanbe Farma
LASI
Non BPJS
OID
BPJS
Generik BPJS
Generik BPJS
Guardian Non BPJS
BPJS
Guardian Non BPJS
Generik BPJS
Soho Non BPJS
BPJS
Guardian Non BPJS
BPJS
Novell Non BPJS
Novell Non BPJS
Nulab Non BPJS
BPJS 90 tab / bulan

Generik BPJS
Generik BPJS
Fahrenheit Non BPJS
Fahrenheit Non BPJS
Generik BPJS
Fahrenheit Non BPJS
BPJS
BPJS
Fahrenheit Non BPJS
Fahrenheit Non BPJS
BPJS
Untk kasus gangguan
tiroid, utk tremor
Generik BPJS essensial, tremor
distonia, tremor
holmes
Generik BPJS
NSI
BPJS 30 tab / bulan

Bernofarm Non BPJS
Guardian Non BPJS
Bernofarm Non BPJS
BPJS 30 tab / bulan

Tanabe BPJS 30 tab / bulan
BPJS
Untuk hipertensi yang

intoleransi terhadap
Generik BPJS
ACE Inhibitor. Maks
30 tab/bln

Bernofarma Non BPJS
Untuk hipertensi yang

intoleransi terhadap
BPJS
ACE Inhibitor. Maks
30 tab/bln

Bernofarma Non BPJS
BPJS 90 tab / bulan

BPJS 90 tab / bulan
BPJS 90 tab / bulan
BPJS
dengan hipertensi
BPJS berat dan memerlukan
Astellas BPJS perawatan
BPJS
Generik BPJS
Fahrenheit Non BPJS
OGENIK
BPJS
BPJS Hanya utk syok

kardiogenik,
dekompensasi kordis
Solvay Pharma Non BPJS akut, dan syok septik
BPJS
Generik BPJS
Fahrenheit Non BPJS
KTIVATOR SEREBRAL
Generik BPJS
Guardian Non BPJS
Generik BPJS
Guardian Non BPJS
Generik BPJS
Non BPJS
EMIA
BPJS Jika setelah pemberian

simvastatin selama 3 bln
berturut-turut pasien
tidak mencapai target
LDL <100mg/dl
Maksimal pemberian
adalah selama 3 bln,
apabila selama 3bln tdk
Generik BPJS mencapai target
dikebbalikan
kepemberian simvastatin
Pasien ASCVD yang

dibuktikan dgn EKG
Fahrenheit Non BPJS atau MSCT atau riwayat
angigrafi,, target LDL
<70mg/dl yg harus
diperiksa setiap 3bln
BPJS
Fahrenheit Non BPJS
BPJS
Hanya untk
hipertrigliserida dgn
kadar TG >250mg/dl
Generik Non BPJS
Pemeriksaan TG
dilakukan pada pasien
yang telah menjalani
puasa
Guardian Non BPJS
hipertrigliseridemia,
BPJS tdk dianjurkan
BPJS diberikan statin
Jika setelah pemberian
simvastatin selama 3 bln
BPJS berturut-turut pasien
tidak mencapai target
LDL <100mg/dl
Maksimal pemberian
adalah selama 3 bln,
apabila selama 3bln tdk
Generik BPJS mencapai target
dikebbalikan
kepemberian simvastatin
Pasien ASCVD yang

dibuktikan dgn EKG
Guardian Non BPJS atau MSCT atau riwayat
angigrafi,, target LDL
<70mg/dl yg harus
diperiksatxsetiap
Adjunct 3bln
diet pasien
hiperlipidemia
dgn:a)kadar LDL > 160
BPJS mg/dl utk pasien tanpa
Generik BPJS komplikasi DM/PJK;
Sanbe Farma Non BPJS b)kadar LDL > 100
mg/dl utk pasien PJK;
Generik BPJS c)kadar LDL> 130
Sanbe Farma Non BPJS mg/dl utk pasien
Kalbe Farma Non BPJS DM.Stlh 6 bln kontrol
diet dan cek lab LDL
dilampirkan tiap 6
ULIT bln.Max 30 tab/bl
Non BPJS
Guardian Non BPJS
TOPIKAL
Non BPJS
Guardian Non BPJS
KORTIKOSTEROID
Guardian Non BPJS
ASIT TOPIKAL
BPJS
Generik BPJS
Sanbe Farma
Non BPJS
Kalbe Farma
GGOROKAN
DAN NUTRISI
Kalbe Farma
Kalbe Farma BPJS
Kalbe Farma
BPJS
Widatra
Sanbe
Non BPJS
Kalbe Farma
Otsuka BPJS
Otsuka BPJS
BPJS
Generik BPJS
BPJS
ERUS
Generik BPJS
Fahrenheit Non BPJS
TIINSOMNIA
Generik BPJS 30 tab/bulan

Mersifarma Non BPJS
Non BPJS
Guardian Non BPJS
Novell Non BPJS
NTIMANIA
BPJS
Generik BPJS
Dexa medica
BPJS

Generik BPJS
Dexa medica
BPJS
Non BPJS
Mersifarma TM Non BPJS

BPJS
Generik BPJS
Guardian Non BPJS
Novell Non BPJS
IS
BPJS
Generik BPJS 90 tab/ bulan
diresepkan oleh
Guardian Non BPJS dokter spesialis
Guardian Non BPJS kejiwaan
MesifarmaTM Non BPJS 4 amp/hari,, maksimal 3 hari
Generik Non BPJS

Guardian Non BPJS
Generik Non BPJS
Guardian Non BPJS
Generik Non BPJS
Guardian Non BPJS 30 tab/ bulan dan
hanya dapat
diresepkan oleh
BPJS dokter spesialis
Mepro BPJS kejiwaan
Novell Non BPJS
BPJS
Generik BPJS 90 tab/bulan
Mersi Non BPJS
Mersi Non BPJS 90 tab/bln,, Hanya utk
pengobatan psikosis
yg sudah resisten
BPJS terhadap antipsikotik
Generik BPJS lain
Guardian Non BPJS
Mersi Non BPJS
Guardian Non BPJS
hanya dapat
diresepkan oleh
BPJS dokter spesialis
Generik BPJS kejiwaan
Guardian Non BPJS
Novell Non BPJS
hanya dapat
diresepkan oleh
dokter spesialis
Generik BPJS kejiwaan
Novell Non BPJS
ERIFER
Combiphar BPJS
Combiphar BPJS
Non BPJS
Guardian Non BPJS
Eisai Non BPJS
BPJS
TIULKUS
30 tab/bln,, utk terapi
jangka pendek pd
Generik BPJS tukak lambung
Lapi Farma Non BPJS
Fahrenheit Non BPJS
Pyridam Farma Non BPJS
Untuk terapi jangka
pendek pada kasus tukak
Generik BPJS lambung, tukak
duodenum dan refluks
Sanbe Farma Non BPJS esofagistis. Diberikan 1
Guardian Pharmatama Non BPJS jam sebelum makan.
Non BPJS Maks 4 minggu/kasus
Sanbe Farma
Guardian Pharmatama Non BPJS
Pyridam Farma Non BPJS
Generik BPJS
Generik BPJS
dine
Generik BPJS
Generik BPJS Maksimal 30 tab/bln
Generik BPJS
Fahrenheit Farma Non BPJS
Guardian Non BPJS
Guardian Non BPJS
mg, magnesium hidroksida

BPJS
Combiphar Non BPJS
Generik BPJS
Generik BPJS
Generik
BPJS
Sanbe Farma
Non BPJS
Generik
BPJS
Sanbe Farma
Non BPJS
Generik BPJS
Generik BPJS
Generik BPJS
Generik BPJS
utylbromide
Interbat Non BPJS
Landson BPJS
Otsuka Non BPJS

Fahrenheit Non BPJS
aracetamol 500mg
Interbat
Non BPJS
Otto
bromide 2,5mg
odil
Boehringer Non BPJS
Boehringer Non BPJS
Boehringer Non BPJS
Otto Non BPJS
Ikapharmindo Non BPJS
Combiphar BPJS
Combiphar BPJS
TOR
holic Acid
Generik BPJS
Dexa Farma Non BPJS
Landson Non BPJS
Generik BPJS
Generik BPJS
Generik BPJS
Novell Non BPJS
Novell Non BPJS
Generik
BPJS
Generik BPJS
Pfizer
Non BPJS
Boehringer
Ingelheim BPJS
Fahrenheit
Non BPJS
Utk terapi rumatan

pada penderita asma.
Tidak utk
bronkhospasme akut.
Astra Zeneca BPJS Rmaks Asma
persisten ringan-
sedang 2 tbg/bln.
Asma persisten berat :
3 tbg/bln
Astra Zeneca BPJS

Glaxo Smith kasus asma akut.
Kline BPJS Maks 1 tbg/bln
Untuk batuk pada
Glaxo Smith PPOK. Maks 1
Kline BPJS tbg/bln
Generik BPJS
Generik BPJS

Generik BPJS
Dexa Farma Non BPJS
GI
Sanbe Farma
Non BPJS
Dexa Farma Non BPJS
Sanbe Farma
Non BPJS
Dexa Farma Non BPJS

Kimia Farma Non BPJS
BPJS

Nulab Farma Non BPJS
Nulab Farma Non BPJS
Guardian
Non BPJS
Pharmatama
PENUNJANG

Royal medika Non BPJS
mg Non BPJS
Dexa Medica
Non BPJS
burmannii Non BPJS

Escolab Non BPJS
Guardian
Non BPJS

BPJS
Generik BPJS
Kalbe Farma
Non BPJS
BPJS
Combiphar BPJS
Combiphar BPJS
Combiphar BPJS
Generik BPJS
Novell Non BPJS

Sanbe Farma
Non BPJS

Sanbe Farma BPJS
largine
Dlm kondisi ttn,

dokter di FKTP dapat
Sanofi Aventis melakukan
BPJS penyesuaian dosis
insulin hingga 20
IU/hari
Sanbe Farma
ulisine
penyesuaian dosis
Sanofi Aventis BPJS insulin hingga 20
IU/hari
Lispro
Ely Lily Non BPJS
etemir dokter di FKTP dapat
melakukan
Novo Nordisk BPJS
penyesuaian dosis
Aspart insulin hingga 20
penyesuaian dosis
Novo Nordisk BPJS insulin hingga 20
IU/hari
Ely Lily Non BPJS

Formularium Rs 2019

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FORMULARIUM RUMAH SAKIT ISLAM SITI HAJAR MATARAM T

SUB KELAS TERAPI DAN BENTUK

Morfin sulfat Tablet MST Continus 10 mg Box 6 x 10 tab

Pethidin inj Pethidin inj Clopedin

ANALGESIK NON NARKOTIK DAN ANTIPIRETIK

Ketorolac Tromethamine ketorolak Larutan Rativol 30 mg Inj

Kombinasi : metampiron 500mg Kombinasi metampiron 500mg dan diazepam 2mg

Kombinasi Paracetamol 500mg Kombinasi Paracetamol 500mg dan N-acetylcystein 200mg

Kombinasi tramadol HCl 3,75mg dan paracetamol 325mg

ANTIINFLAMASI NON STEROID

Ketoprofen Tablet 50mg Kaltrofen 50 mg Tab

Allopurinol Puricemia 300 mg Tab

Benoxuric 300mg Tab

Tablet 60mg Orinox 60mg

OBAT UNTUK PROSEDUR PRE OPERATIF

Tablet 2 mg Valisanbe 2mg tab

ANESTESI LOKAL DAN UMUM

ANTIALERGI DAN OBAT ANAFILAKSIS

Kombinasi betamethasone Kombinasi betamethasone 0,25mg dan dexchlorpheniramine maleat 2mg

ANTIEPILEPSI DAN ANTIKONVULSI

ANTINYERI PADA SARAF

Tablet Sanpicillin 500 mg Kaps

Kombinasi Trimethoprim 80mg Kombinasi Trimethoprim 80 mg dan sulfamethoxazole 400 mg

Kombinasi Trimethoprim 16mg Kombinasi Trimethoprim 160 mg dan sulfamethoxazole 800 mg

Tablet Zibramax 500 mg Tab

Erysanbe Syr Erythromycin

Baquinor Forte Tab

L-Q 500 mg tab

Sirup Colsancetin Syr

ANTIBAKTERI GOLONGAN LAIN

ANTISEPTIK SALURAN KEMIH

OBAT UNTUK SALURAN KEMIH DAN PROSTAT

Kombinasi Metronidazole 500mg, nystatin 100.000 IU

ANTIAMUBA DAN ANTIGIARDIASIS

Betahistine mesylate Tablet

NOOTROPIK DAN NEUROTONIK

ANTIKOAGULAN DAN ANTIPLATELET

Esktrak akar litospermi 0,09, etil

Ekstrak akar litospermi 0,1mg,

Hemapo 3.000 IU Inj

Eprex 4000 IU Inj

PENGGANTI PLASMA DAN PLASMA EXPANDER

Methylprednisolone 125mg inj

Propranolol Propranolol 10mg

OBAT SYOK KARDIOGENIK

VASODILATOR PERIFER DAN AKTIVATOR SEREBRAL

Citicoline 250 mg inj

ANTIFUNGI TOPIKAL DENGAN KORTIKOSTEROID

Kombinasi (per gram krim) :

ANTIFUNGI DAN ANTIPARASIT TOPIKAL

b. Hydrogenated castor oil,

SEDIAAN ELEKTROLIT DAN NUTRISI

Tutofusin OPS Inf

Kombinasi (per liter larutan) : Widahes 200

c. Larutan Na lactate 4,48%

Kombinasi (per liter larutan) :

ANTIANSIETAS DAN ANTIINSOMNIA