FORMULARIUM OBAT [BPJS]

KLINIK PRATAMA SANTA MARIA

TAHUN 2023
DOSIS
NO NAMA OBAT KANDUNGAN GOLONGAN SEDIAAN
SEDIAAN
1 Aciclovir 400 mg Aciclovir Antivirus tablet
2 Paracetamol 500 mg Parasetamol Analgetik & Antipiretik tablet
3 Paracetamol 120 mg / 5 ml Parasetamol Analgetik & Antipiretik sirup
4 Antasida Doen 500 mg Antasida Doen Antasida tablet
5 Ranitidin 150 mg Ranitidin Antasida tablet
6 Glibenclamide 5 mg Glibenclamide Anti Diabetik kaplet
7 Metformin 500 mg Metformin Anti Diabetik tablet
8 Metformin 850 mg Metformin Anti Diabetik tablet
9 Neodiaform - Kaolin 550mg Pectin 20mg Anti Diare tablet
10 Tranexamic Acid 500 mg Asam Traneksamat Anti Fibrinolitik kaplet
11 Miconazole 2% Miconazole Anti Fungi salep
12 Fargetix 500 mg Asam Mefenamat Anti Inflamasi Non-Steroid tablet
13 Farsifen 200 mg Ibuprofen Anti Inflamasi Non-Steroid tablet
14 Farsifen 400 mg Ibuprofen Anti Inflamasi Non-Steroid tablet
15 Megatic 50 mg Natrium Diklofenak Anti Inflamasi Non-Steroid tablet
16 Metamizole 500 mg Metamizole Anti Inflamasi Non-Steroid tablet
17 Piroxicam 20 mg Piroxicam Anti Inflamasi Non-Steroid tablet
R150 H75 Z400
18 FDC I E275 FDC Anti TB tablet

19 FDC II R150 H150 FDC Anti TB tablet

Trimetoprim 80 mg
20 Cotrimoxazole - Antibiotik & Antijamur tablet
Sulfamethoxazole 400 mg
21 Gentamycin 0.10% Gentamycin Antibiotik Aminoglikosida salep
22 Metronidazole 500 mg Metronidazole Antibiotik Nitromidazole tablet
23 Amoxicillin 500 mg Amoxicillin Antibiotik Penisilin tablet
24 Yusimox 125 mg / 5 ml Amoxicillin Antibiotik Penisilin sirup
25 Ciprofloxacin 500 mg Ciprofloxacin HCl Antibiotik Quinolon tablet
26 Domperidon 10 mg Domperidon Antiemetik tablet
27 Hufadon 10 mg Domperidon Antiemetik tablet
28 Cetirizine 10 mg Cetirizine HCl Antihistamin tablet
29 CTM 4 mg CTM Antihistamin tablet
30 Histigo 6 mg Betahistine Antihistamin tablet
31 Omedrinat 50 mg Dimenhydrinate Antihistamin tablet
32 Winatin 10 mg Loratadin Antihistamin tablet
33 Papaverin HCl 40 mg Papaverin HCl Antispasmodik tablet
34 Aciclovir 5% Aciclovir Antivirus salep
35 Amlodipin 5 mg Amlodipin Calcium-Channel Blockers tablet
36 Amlodipin 10 mg Amlodipin Calcium-Channel Blockers tablet
37 Cefadroxil 500 mg Cefadroxil Cefalosporin kapsul
38 Gencef 125 mg / 5 ml Cefadroxil Cefalosporin sirup
39 HCT 25 mg HCT Diuretik tablet
40 Pharolit - Oralit Elektrolit bubuk
41 Dexamethasone 0,5 mg Deksametason Kortikosteroid tablet
42 Hidrokortison 2.50% Hidrokortison Kortikosteroid salep
43 Prednison 5 mg Prednison Kortikosteroid tablet
 DOSIS
NO NAMA OBAT KANDUNGAN GOLONGAN SEDIAAN
SEDIAAN
44 Ambroxol HCl 30 mg Ambroxol HCl Mukolitik tablet

45 Allopurinol 100 mg Allopurinol Penghambat Xanthine-Oxidase tablet

46 Simvastatin 10 mg Simvastatin Statin tablet

47 Simvastatin 20 mg Simvastatin Statin tablet
48 Calcium Lactate 500 mg Kalsium Laktat Suplemen tablet
49 Tyalisin - Curcuma Suplemen sirup
50 Vit. B 1 - Tiamin Suplemen tablet
51 Vit. B 12 - Cobalamin Suplemen tablet
52 Vit. B 6 - Piridoksin Suplemen tablet

53 Vit. B Kompleks - B1, B2, B3, B5, B6, B7, B9,dan B12 Suplemen tablet

Ditetapkan pada,
Senin 23 Januri 2023

Hormat kami, Menyetujui, Mengetahui,

Brigitta Rani dr. Lidya Gracy Tumewu Sr. Adelheit Rembuk, FMM
Asisten Apoteker Kepala Klinik Koord. Klinik
 FORMULARIUM OBAT [UMUM]
KLINIK PRATAMA SANTA MARIA
TAHUN 2023

NO NAMA OBAT DOSIS SEDIAAN KANDUNGAN GOLONGAN SEDIAAN

1 Aciclovir 400 mg Aciclovir Antivirus tablet

2 Captopril 25 mg Captopril ACE Inhibitor tablet
Parasetamol, Phenylpropanolamine
3 Decolgen - Analgesik tablet
HCl, CTM
Analgetik &
4 Metamizole 500 mg Metamizole tablet
Antipiretik
Analgetik &
5 Sumagesic 600 mg Parasetamol tablet
Antipiretik
Analgetik &
6 Dumin 500 mg Parasetamol tablet
Antipiretik
Analgetik &
7 Fasidol drop 60 mg / 0.6 ml Parasetamol drop
Antipiretik
Analgetik &
8 Itramol 120 mg / 5 ml Parasetamol sirup
Antipiretik
Analgetik &
9 Pamol supp. 125 mg Parasetamol suppositori
Antipiretik
Analgetik &
10 Pamol supp. 250 mg Parasetamol suppositori
Antipiretik
11 Disflatyl 40 mg Simeticon Antagonis H2 tablet
Mg Trisilicate, Al Hydroxide,
12 Lexacrol - Antasida tablet
Simethicone
13 Ranitidin 150 mg Ranitidin Antasida tablet
14 Anflat - Mg(OH)2 Antasida sirup
15 Sucralfat syrup - Sukralfat Antasida sirup
16 Antasida Doen - Al Hydroxide, Mg Hydroxide Antasida tablet
17 Glibenclamide 5 mg Glibenclamide Anti Diabetik tablet
18 Metformin 500 mg Metformin Anti Diabetik tablet
19 Metformin 850 mg Metformin Anti Diabetik tablet
20 Neodiaform - Kaolin 550mg, Pectin 20mg Anti Diare tablet
21 Lopamid 2 mg Loperamide HCl Anti Diare tablet
22 Kalnex 500 mg Asam Traneksamat Anti Fibrinolitk tablet
Anti Inflamasi Non-
23 Neurophyron V - Metampiron, Vit. B1, Vit. B6, Vit. B12 kaplet
Steroid
Anti Inflamasi Non-
24 Piroxicam 10 mg Piroxicam tablet
Steroid
Anti Inflamasi Non-
25 Piroxicam 20 mg Piroxicam tablet
Steroid
Anti Inflamasi Non-
26 Ponstelax 500 mg Asam Mefenamat tablet
Steroid
Anti Inflamasi Non-
27 Renadinac 50 mg Natrium Diklofenak tablet
Steroid
Anti Inflamasi Non-
28 Arcoxia 90 mg Etoricoxib tablet
Steroid
 Menthol 55mg, Eugenol 14mg, Methyl
Salicylate 102mg, Capsicum Anti Inflamasi Non-
29 Lafalos - krim
Oleoresin / Capsaicin 0.3mg, Vit. E Steroid
Acetate 30mg

NO NAMA OBAT DOSIS SEDIAAN KANDUNGAN GOLONGAN SEDIAAN

30 Proris supp. 125 mg Ibuprofen Anti Inflamasi Steroid suppositori

31 Ethambutol 500 mg Ethambutol Anti TB tablet

32 Inoxin 400 mg INH 400 mg B6 10mg Anti TB tablet
33 Rifampicin 600 mg Rifampicin Anti TB tablet
34 Rifabiotik 450 mg Rifampicin Anti TB tablet
35 Pyrazinamide 500 mg Pirazinamide Anti TB tablet
36 FDC I - R150 H75 Z400 E275 Anti TB tablet
37 FDC II - R150 H150 Anti TB tablet
Trimethoprim 160mg Antibiotik &
38 Primadex Forte - tablet
Sulfamethoxazole 800mg Antijamur

39 Primadex syrup - Trimethoprim 40mg Sulfamethoxazole Antibiotik & sirup

200mg Antijamur
Antibiotik
40 Gentamycin 0.10% Gentamycin salep
Aminoglikosida

41 Erlamycetin Salep Mata 1% Chloramphenicol Antibiotik Bakterisidal salep

42 Erlamycetin Tetes Telinga 1% Chloramphenicol Antibiotik Bakterisidal drop

Antibiotik Bakterisidal
43 Erlamycetin Tetes Mata - Chloramphenicol, Dexamethasone drop
& Kortikosteroid

Antibiotik
44 Levofloxacin 500 mg Levofloxacin tablet
Fluorokuinolon
Antibiotik
45 Dionicol 125 mg / 5 ml Thiamphenicol sirup
Kloramfenikol
Antibiotik
46 Incocyn 500 mg Lincomycin Lincosamide kapsul

Antibiotik
47 Clindamycin 300 mg Clindamycin Lincosamide tablet

48 Spyramicin 500 mg Spiramycin Antibiotik Makrolida tablet

49 Azithromycin 500 mg Azithromycin Antibiotik Makrolida tablet

50 Metronidazole 500 mg Metronidazole Antibiotik tablet

Nitroimidazole
51 Topcillin 500 mg Amoxicillin Antibiotik Penisilin tablet
52 Yusimox syrup 125 mg / 5 ml Amoxicillin Antibiotik Penisilin sirup

53 Floxifar 500 mg Ciprofloxacin Antibiotik Quinolone kaplet

54 Ciprofloxacin 500 mg Ciprofloxacin Antibiotik Quinolone tablet

55 Bioplacenton - Placenta Extract, Neomycin Sulfate Antibiotik Topikal gel

56 Omedom 10 mg Domperidone Antiemetik tablet

57 Ondansetron 8 mg Ondansetron Antiemetik tablet
58 Damaben 10 mg Metoclopramide HCl Antiemetik drop
59 Omedom syrup 10 mg Domperidone Antiemetik sirup
60 Ardium 500 mg Flavonoid Antihemoroid tablet
61 Allohex 10 mg Loratadin Antihistamin tablet
62 Cetirizine HCl 10 mg Cetirizine HCl Antihistamin tablet
63 Histigo 6 mg Betahistine Mesilate Antihistamin tablet

NO NAMA OBAT DOSIS SEDIAAN KANDUNGAN GOLONGAN SEDIAAN

64 Pronam 4 mg Ciproheptadine HCl Antihistamin kaplet

65 Antimo 50 mg Dimenhydrinate Antihistamin tablet
66 Stugeron 25 mg Cinnarizine Antihistamin tablet
67 CTM 4 mg Chlorpheniramine Maleat Antihistamin tablet
68 Calamed - - Antihistamin lotion
Phenylpropanolamine HCl, Antihistamin &
69 Nalgestan - tablet
Chlorpheniramine Maleate Vasokonstriktor
70 Griseofulvin 500 mg Griseofulvin Antijamur tablet
71 Miconazole 2% Miconazole Antijamur krim
72 Cazetin - Nistatin Antijamur drop
73 Gabapetin 300 mg Gabapentin Antikonvulsan tablet
74 Buscopan 10 mg Hyoscine N-butylbromid Antimuskarinik tablet
75 GOM - Boraks Gliserin Antiseptik drop
76 Betadine Gurgle - Povidone Iodine Antiseptik cair
Permanganas Kalikus / Potassium
77 PK - Antiseptik bubuk
Permanganate
Hyoscine N-butylbromid 10mg PCT
78 Spasminal - Antispasmodik tablet
500mg
79 Papaverin HCl 40 mg Papaverin HCl Antispasmodik tablet
80 Poviral 400 mg Aciclovir Antivirus tablet
81 Aciclovir 5% Aciclovir Antivirus krim
82 Salbutamol 2 mg Salbutamol Bronkodilator tablet
83 Salbutamol 4 mg Salbutamol Bronkodilator tablet
84 Aminophyllin 200 mg Aminofilin Bronkodilator tablet
Calcium Channel
85 Amlodipine 5 mg Amlodipine Besilate Blockers tablet

Calcium Channel
86 Amlodipine 10 mg Amlodipine Besilate Blockers tablet

Calcium Channel
87 Hexavask 5 mg Amlodipine Besilate tablet
Blockers
88 Cefadroxil 500 mg Cefadroxil Cefalosporin kapsul
89 Lostacef 500 mg Cefadroxil Cefalosporin kapsul
90 Lostacef syrup 125 mg / 5 ml Cefadroxil Cefalosporin sirup
91 Lostacef syrup 250 mg / 5 ml Cefadroxil Cefalosporin sirup
92 HCT 25 mg Hydrochlorothiazide Diuretik tablet
93 Pharolit - Oralit Elektrolit bubuk
94 Gemfibrozil 300 mg Gemfibrozil Fibrat tablet
95 Metilprednisolon 8 mg Metilprednisolon Glukokortikoid tablet
96 Metilprednisolon 4 mg Metilprednisolon Glukokortikoid tablet
97 Batugin - Herbal Jamu sirup
98 Salicyl Talk - Asam Salicylate Keratolitik bubuk
99 Dexycol 500 mg Thiamphenicol Kloramfenikol kapsul
100 Benodex 0,5 mg Deksametason Kortikosteroid tablet
101 Dexamethasone 4 mg Deksametason Kortikosteroid tablet
102 Prednison 5 mg Prednison Kortikosteroid tablet
Betamethasone valerate, Neomycin
103 Betason N - Kortikosteroid krim
Sulfate
104 Hidrokortison 1% Hidrokortison Kortikosteroid krim
105 Hidrokortison 2.50% Hidrokortison Kortikosteroid salep
Kortikosteroid &
106 Dexteem Plus - Deksametason, Dexchlorpheniramine tablet
Antihistamin

NO NAMA OBAT DOSIS SEDIAAN KANDUNGAN GOLONGAN SEDIAAN

107 Ambroxol 30 mg Ambroxol HCl Mukolitik tablet

108 Acetylcysteine 200 mg Acetylcysteine Mukolitik kapsul
109 Exovon 8 mg Bromhexin HCl Mukolitik tablet
Dextromethorphan HBr 15mg,
110 Grantusif - Guaifesin 100mg, Diphenhydramine Mukolitik tablet
HCl 5mg
Succus Kiquiritiae, Ammonium
111 OBH syrup - Mukolitik sirup
Chloride, Sasa

112 OBP syrup - Ammonium Chlorida, Amonium Mukolitik sirup

Liquida, OI. Menthae Piperithiae
113 Estalex 50 mg Eperisone HCl Muscle Relaxant tablet
114 Isosorbide Dinitrate 5 mg Isosorbide Dinitrate Nitrat tablet
115 Dulcolax 5 mg Bisacodil Pencahar tablet
Penghambat
116 Allopurinol 100 mg Allopurinol tablet
Xanthine-Oxidase
Proton Pump
117 Lansoprazole 30 mg Lansoprazole kapsul
Inhibitor
118 Atorvastatin Calcium 20 mg Atorvastatin Calcium Statin tablet
119 Simvastatin 10 mg Simvastatin Statin tablet
120 Simvastatin 20 mg Simvastatin Statin tablet
121 Caviplex - Multivitamin Suplemen kaplet
Glucosamine, Chondroitin,
122 Osteokom - Suplemen kaplet
Methylsulfonylmethane
123 Asam Folat 400 mcg Asam Folat Suplemen tablet
124 Asam Folat 1 mg Asam Folat Suplemen tablet
Fe Gluconate, Mn Sulfate, Copper
125 Sangobion - Sulfate, Vit. C, Folic Acid Suplemen tablet

126 Zinc Sulfat 10 mg Zinc sulphate Suplemen tablet

127 Vitamin C 250 mg Asam Askorbat Suplemen tablet
128 Livron B-plex - Multivitamin Suplemen tablet
129 Fundamin E - Multivitamin Suplemen tablet
130 Mecobalamin 500 mcg Mecobalamin Suplemen kapsul
131 Tialysin - Vitamin Curcuma Suplemen sirup
132 Curbion Kids Vitamin Curcuma Suplemen sirup
133 Calcium Lactat 500 mg Kalsium Laktat Suplemen tablet
134 Aspar K 100 mg Kalium I-Aspartate Suplemen tablet
135 Vitamin B6 10 mg Pyridoxine Suplemen tablet
136 Vitamin D3 1000IU Cholecalciferol Suplemen tablet

137 L-Bio - Probiotik Lactobacillus acidophilus Suplemen bubuk

138 Curcuma caps - Curcuma Herbal Suplemen kapsul

Ditetapkan pada,
Senin 23 Januri 2023

Hormat kami, Menyetujui, Mengetahui,

Brigitta Rani dr. Lidya Gracy Tumewu Sr. Adelheit Rembuk, FMM
Asisten Apoteker Kepala Klinik Koord. Klinik