FORMULARIUM PASIEN BPJS

RS. NAHDLATUL ULAMA BANYUWANGI

TAHUN 2024
• GOLONGAN ANTIBIOTIK

NO NAMA GENERIK NON GENERIK

1 Amoxicillin 500 mg kapsul Amoxsan 500mg kapsul
Amoxicillin 125mg/5ml syrup Amoxsan Forte 250mg/5ml syrup
Amoxicillin 250mg/5ml syrup Amoxsan 125 mg/5ml dry syrup
Amoxicilliin 100mg/ml drop Amoxsan 100mg/drops
2 Ampicillin Sulbactam
3 Azythromycin 500mg tablet
4 Ciprofloksasin 500mg tablet
ciprofoxacin TM
Ciprofloksasin 200mg/100ml infus
5 Thiamfenicol 500 mg kapsul Biothicol 500 mg kapsul
Thiamfenicol 125mg/5ml syrup Biothicol syrup
6 Cefadroxyl 500 mg kapsul
Cefadroxyl 125mg/5ml syrup
Cefadroxyl 250 mg/5ml syrup
7 Cefrixime 100mg kapsul
Cefixime 100mg/5ml syrup

8 Cefotaxim 1 gram injeksi

Cefotaxim 0,5 gram injeksi
9 Cefoperazone 1 gram injeksi
10 Ceftriaxon 1 gram injeksi
11 Chloramphenicol TM Erlamicetin TM
Reco TM
RecoSM
Chloramphenicol TT
12 Co amoxiclav 625 mg kapsul
Co amoxiclav 1 gram injeksi
Co amoxiclav 125 mg/5ml syrup
13 Clindamycin 150 mg kapsul
Clindamycin 300mg kapsul
14 Doxycyclin 100mg kapsul
15 Erythromicin 500mg tablet
Erythromicin 250 mg
Erythromicin syrup
16 Ethambutol 500mg tablet

1
17 Metronidazol 500 mg tablet
Metronidazol 500mg/100ml infus
Metronidazole suppositoria Vagizol
Metronidazol 500 mg/ml syrup
18 Gentamicin 40mg/ml injeksi
Gentamicin SM genoin SM
Gentamicin cream Genoin Cream
19 Amikasin 125 mg/ml injeksi
20 INH 100 mg tablet
INH 300 mg tablet
INH 400 mg tablet
21 Levofloxacin 500 mg tablet
Levofloxacin 500 mg/ 100 ml infus
22 Meropenem 0,5 gr injeksi
Meropenem 1 gr injeksi
23 Neomycin salep/tabur Enbatic salep/tabur
24 Oxytetracyclin salep mata
25 Pyrazinamide 500 mg tablet
26 Rifampicin 300 mg kapsul
Rifampicin 450 mg kapsul
Rifampicin 600 mg kapsul
27 Cotrimoxazole 240 mg tablet Sanprima tablet
Cotrimoxazole 480 mg tablet Sanprima forte tablet
Cotrimoxazole 120 mg/5 ml syrup
28 Asam pipemidat 400mg/kapsul Urinter kapsul
• GOLONGAN ANTI FUNGI

1 Miconazole nitrate 2%
2 Ketoconazole 200 mg tablet
Ketoconazole 2% cream
3 Nystatin 100.000IU/ml
• GOLONGAN OBAT ANTIHIPERTIROID

1 PTU 100mg tablet

2 Tiamizol 5mg tablet Thyrozol 5mg tablet
Tiamizol 10mg tablet thyrozol 10mg tablet

2
 • GOLONGAN ANTI ALERGI

1 Loratadine 10 mg tablet
2 Cetirizine 10 mg tablet
Cetirizine 5 mg/ 5 ml syrup
3 Cetirizine 10 mg/ml drops
4 Mebhydrolin 50 mg tablet Interhistin tablet
5 Ciproheptadin 4mg tablet Heptasan tablet
6 CTM 4mg tablet
CTM plus betametason tablet Grafachlor
• GOLONGAN ANTI ASMA

1 Salbutamol 2 mg tablet
Salbutamol 4 mg tablet
Salbutamol inhaler Ventolin inhaler
2 Salbutamol 2,5 mg Nebul Ventolin Nebule
Ipratrium br 21 mcg, salb 120 mcg Combiven nebule
3 Theophylin 300mg SR kapsul Retaphyl tablet
4 Theophylin 130mg kapsul
5 Ketotifen 1 mg tablet
6 Aminophyllin 24mg/ml injeksi

• GOLONGAN NASAL DEKONGESTAN, ANTITUSIF DAN

INFLUENZA

1 Tripolidine 2,5 mg tablet + Tremenza tablet

2 Paracetamol 500mg, PPA 12,5mg, CTM 2mg, Alpara tablet
DMP 15mg Tuzalos tablet
3 Paracetamol 125mg, PPA 3,125mg, CTM 0,5mg, Alpara syrup
DMP 3,75mg
4 Paracetamol 500mg, PPA 12,5mg, CTM 2mg, Molexflu tablet
DMP 10mg, GG 50mg, PPA 12,5mg,CTM 1mg Dextral tablet
5 Diphenhidramine 12,5mg, Amm klorida 100mg Sanadryl exp syrup
6 DMP 10mg, diphenhidramin,amm klorida Sanadryl DMP syrup

3
 • GOLONGAN NSAID

1 Natrium Diclofenac 50 mg tablet renadinac

Natrium Diclofenac 20 gram gel
2 Kalium Diclofenac 50 mg tablet
Dexketoprofen 25 mg tablet
3 Meloxicam 7,5 mg tablet
Meloxicam 15 mg tablet
4 Methampyron 500 mg, Vit B1 50 mg,
Vit B6 100 mg, Vit B12 100 mcg tablet Neurosanbe plus
5 Ketorolac Tromethamine 30 mg/ml
6 Ketorolac Tromethamine 10 mg tablet
7 Ketoprofen 100 mg tablet
Ketoprofen 100 mg supp
8 Piroxicam 20 mg kapsul
Methampyron 500 mg, diazepam 2mg
9
tablet Analsix tablet
Tramadol injeksi

GOLONGAN KORTIKOSTEROID

1 Mometasone Furoate 0,1% cream 5 gr

2 Methylprednisolone 4 mg tablet
Methylprednisolone 8 mg tablet
Methylprednisolone 16 mg tablet
Methylprednisolone 125 mg injeksi
Methylprednisolone 500 mg injeksi
3 Dexamethasone 0,5 mg
Dexamethasone 5 mg/ml
4 Betamethasone cream
5 Desoximethasone cream

• GOLONGAN ANTIBIOTIK + KORTIKOSTEROID TOPIKAL

1 Betamethasone + Neomycin cream Cinolon

2 Betamethasone + Gentemycin cream

4
 • GOLONGAN ANTI VIRAL

Acyclovir 200 mg tablet

1 Acyclovir 400 mg tablet
Acyclovir cream

• GOLONGAN ANTIPIRETIK / ANALGESIK

1 Paracetamol 500 mg tablet

Paracetamol 120 mg/5 ml
Paracetamol 60 mg/0,6 ml drops Sanmol drops
Paracetamol 125 mg supp Pamol supp
Paracetamol 100 mg/100 ml infus
2 Asam Mefenamat 500 mg
3 Ibuprofen 200 mg tablet
Ibuprofen 400 mg tablet
Ibuprofen 100 mg/5 ml suspensi
4 Metamizole 500 mg tablet Antrain tablet
Metamizole 500 mg/ml injeksi Antrain injeksi
Santagesic injeksi
Metamizole 500 mg/5 ml syrup

• ANTI MUAL DAN MUNTAH

1 Metoclopramide 10 mg tablet
Metoclopramide 5 mg/ml injeksi
2 Ondansetron 4 mg tablet
Ondansetron 8 mg tablet
Ondansetron 4 mg/ 2 ml injeksi
3 Domperidone 10 mg tablet
Domperidone 5 mg/5ml syrup
Domperidone 5 mg/ml drops
4 Pyrathiazine Theoclate + Pyridoxine Vomil B6 tablet

5
 • GOLONGAN ANTI ULKUS PEPTIKUS

1 Omeprazole 20 mg kapsul
Omeprazole 40 mg injeksi
2 Pantoprazole 40 mg injeksi
3 Ranitidin 25 mg/ml injeksi
Ranitidin 150 mg tablet
Sucralfate 500 mg/5ml syrup
4 Magnesium Hydroxide, Magnesium,
Simethicone tablet
5 Magnesium Hydroxide, Magnesium,
Simethicone syrup
6 Dimetilpolisiloksan Disflatyl tablet
7 Misoprostol
8 Simetidin 200 mg tablet
Clidinium bromide 2,5mg, klordiazepoksid
9
5mg Braxidine tablet
10 Antasida plus kordiazepoksid 5mg tablet Sanmag Tablet
11 Hiosine 10 mg tablet
12 Hiosine + paracetamol 500mg scofa
13 Hiosine injeksi

6
 • GOLONGAN CEREBROVASKULER

1 Flunarizine 5 mg tablet
2 Flunarizine 10 mg tablet
3 Betahistin Maleat 6mg tablet
4 Piracetam 1 gr injeksi
5 Piracetam 3 gr injeksi
6 Piracetam 800 mg tablet
7 Piracetam 1200 mg tablet
8 Donepezil
9 Citicoline 500 mg tablet
10 Citicoline 250 mg injeksi
Citicoline 500 mg injeksi

• GOLONGAN NEUROTROPIK VITAMIN

1 Vit B1 100 mg, B6 200 mg, B12 200 mcg Neurodex tablet
Nerosanbe inj
Zyfort inj
2 Mecobalamin 500 mcg
Mecobalamin 500 mcg injeksi
3 Vitamin B1 aktif Furamin injeksi
4 Vitamin B1 50mg tablet
5 Vitamin B6 10mg tablet
6 Vitamin B12 50 mikrogram tablet
7 Vitamin B complex tablet

• GOLONGAN SUPLEMEN, VITAMIN DAN OBAT LAIN

1 Kalsium Karbonat 1250mg Osteocal tablet

2 Calcuim Lactate, Vit B6, Vit C, Vit D3 Elkana tablet
3 Curcumae tablet Curcuma tablet
4 Curcumae + Vit lain syrup
Omega 3 64,5 mg, EPA/DHA 48,5/12,5 MG
5
Asam Folat 400 mcg dan vit lain Folamil Genio kapsul
Folavit tablet
Santa E kapsul 200mcg
6
Vitamin E 200 mcg kapsul
7 Zinc Sulphate 20 mg/5 ml syrup
Zinc Sulphate 20 mg tablet
8
Essential Keto acid Aminefron

7
 9 Lecithin 150mg dll heparmin
10 Sericocalyx folium dll Kejibeling
Glukosamin 500 mg Glucosamin tablet
11
Glukosamin1500 mg GCM Forte tablet
12 Vitamin C 50mg/ml inj
13 Vitamin C100 mg tablet
14 Vitamin B complex + Vit C 500mg Becom C tablet
Multivitamin tablet
Lacto bacillus L-bio sachet

15

Extract guajava 300mg Trombofit sachet

16

17 Vitamin D3(Calcitriol) 0,25mikrogram

18 Asam Hyaluronat 1% inj
19 Ursodeoxy 250mg kapsul

• GOLONGAN ANTI ANEMIA

1 Fe Fumarate 250 mg, dll

2 Fe Fumarate 360 mg, dll

• GOLONGAN ANTIKOAGULAN, ANTI PLATELET DAN

TROMBOLITIK

1 Silostazol 100mg tablet Pletaal 100 mg tab

2 Asam asetilsalisilat 80mg Aspilet tablet
Miniaspi
3 Klopidogrel 75 mg
4 Beraprost Sodium
5 Carbazokrom 10mg /tablet
Carbazokrom 5mg/5ml inj
Asam traneksamat 500mg tablet
6 Asam traneksamat 50mg/ml inj
7 Enoxaparin Lovenox
8 Vitamin K 2mg/ml
9 Vitamin K 10mg/ml
10 Fondaparinuks 2,5 mg/0,5ml Venax injeksi

8
 • GOLONGAN PRODUK DARAH DAN PENGGANTI PLASMA

1 Human Albumin 20% 50 ml

2 Human Albumin 20% 100 ml
HES 130 Widahes infus
3 Voluven infus

• GOLONGAN MUKOLITIK

1 Ambroxol 30 mg tablet
2 Ambroxol 15 mg/5 ml syrup
3 Ambroxol 15 mg/ml drops
4 Erdostein 300 mg
5 Bromhexine 8 mg
6 Bromhexine 4 mg/5 ml syrup
7 N. Acetylsistein 200 mg kapsul
• GOLONGAN ANTI DIARE

1 Attapulgite Neo Diatab tablet

2 Loperamide

• GOLONGAN TRANQUILIZER + PSIKOFARMAKA

1 Alprazolam 0,25 mg tablet
Alprazolam 0,5 mg tablet
2 Haloperidol 0,5 mg
Haloperidol 2 mg
Haloperidol 5 mg tablet
3 Clobazam 10 mg tablet
4 Diazepam 2 mg tablet
Diazepam 5 mg tablet
Diazepam 5 mg/ml injeksi
Diazepam 5 mg sup
5 Midazolam 5 mg/5 ml injeksi
6 Amitriptiline 25mg tablet
7 Fluoxetin 20 mg tablet Elizac tablet
8 Klorpromazine 100mg tablet cepezet tablet
Klorpromazine 25mg/ml injeksis cepezet injeksi
9 Trifluoperazin 5 mg tablet

9
 • GOLONGAN RELAKSAN OTOT PERIFER DAN PENGHAMBAT
KOLINESTERASE

1 Atrakurium besilat 25mg/2,5ml inj

2 Eperison 50mg tablet
3 Neostigmin 0,5mg/ampul
4 Tizanidine 2 mg tablet

• GOLONGAN ANTI EPILEPSI + ANTIPARKINSON

1 Carbamazepin 200mg tablet Bamgetol tablet

2 Trihexyphenidyl 2mg
3 Asam valproat 500mg tablet
Asam valproat 250mg tablet
Asam valproat 50mg/ml syrup
4 Penitoin 100mg tablet
Penitoin 50mg /ml injeksi
5 Gabapentin 100 mg
Gabapentin 300 mg
6 Pregabalin 75 mg
7 Phenobarbital 30 mg tablet
Phenobarbital 200mg/2mlinj Sibital inj
8 Levodopa 100mg, benserazide HCl 25mg Levopar tablet
9 Pramipeksol 0,375 mg
Pramipeksol 0,250 mg
• GOLONGAN ANTIDIABETIK ORAL

1 Metformin 500 mg tablet

2 Glimepiride 1 mg tablet
Glimepiride 2 mg tablet
Glimepiride 3 mg tablet
Glimepiride 4 mg tablet
3 Glibenclamide 5 mg tablet
4 Gliclazide 80mg tablet
5 Gliquidon 30mg tablet
6 Pioglitazone 15 mg tablet
7 Pioglitazone 30 mg tablet
8 Acarbose 50mg tablet
Acarbose 100mg tablet

10
 • GOLONGAN INSULIN

1 Insulin aspart 100 iu/ml Sansulin rapid

2 insulin lispromix 100 ui/ml Humalog mix flexpen
Novomix flexpen
3 Insulin detemir 100 iu/ml Sansuline log G
4 Insulin glargine 100 iu/ml Sansuline log G
• GOLONGAN ANASTESI UMUM

1 Ketamin HCl 100 mg/ ml KTM injeksi

2 Bupivacain 5mg/ml
3 Lidocain2%, ephineprin Pehacain injeksi
4 Lidocain2% injeksi
5 Propofol 10mg/ml injeksi
6 Halothan
7 Isofluran
8 Morfin injeksi

• GOLONGAN KARDIOVASKULER

1 Nifedipin 10mg tablet Nifedin tablet

2 Nitrogliserin inj NTG injeksi
Nitrogliserin tablet Nitrokaf Retard
3 ISDN 5mg tablet
ISDN 1mg/ml
4 Diltiazem 30mg tablet
Diltiazem 50mg/ml injeksi Farmabes injeksi
5 Amiodaron 200 mg/tablet
Amiodaron 50 mg/ml injeksi
6 Kaptopril 12,5 mg tablet
7 Kaptopril 25 mgtablet
8 Ramipril 2,5 mgtablet
Ramipril 5mg tablet
Ramipril 10 mg tablet
9 Lisinopril 5mg tablet
Lisinopril 10mg tablet
10 Valsartan 80 mg tablet
Valsartan 160 mg tablet
11 Bisoprolol 5mg tablet
Bisoprolol 2,5mg tablet
12 Propanolol 10mg tablet
Propanolol 40mg tablet
13 Amlodipin 5mg tablet
Amlodipin 10mg tablet
14 Nimodipin 30mg tablet
Nimodipin 0,2mg /ml injeksi

11
15 Nicardipin 1mg/ml
16 Irbersartan 150mg tablet
Irbersartan 3000mg tablet
17 Candesartan 8mg tablet
Candesartan 16mg tablet
18 Telmisartan 40 mg tablet
19 Telmisartan 80 mg tablet
20 Metyldopa 250mg tablet Dopamet tablet
21 Digoxin 0,25mg tablet
Digoxin injeksi
22 Dopamin 10mg/ml
23 Dobutamin 50mg/ml
24 ephinephrin1mg/ml inj
25 Norephineprin 1mg/ml
26 Atorvastatin 20mg tablet
Atorvastatin 40mg tablet
27 Simvastatin 10mg tablet
Simvastatin 20mg tablet
28 Rosurvastatin 20mg tablet
29 Gemfibrosil 300 mg kapsul
30 Fenofibrate 100mg kapsul
Fenofibrate 300mg kapsul
31 Trimetazidine tablet Angintriz tablet
32 Carvedilol V- bloc
• GOLONGAN DIURETIK

1 Furosemid 40mg tablet

Furosemid 10mg/2ml inj
2 Spironolacton 25mg tablet
Spironolacton 100mg tablet
3 HCT 25mg tablet
4 Manitol
5 Asetazolamide 250mg tablet Glauceta tablet
• GOLONGAN ANTIPIRAI

1 Allopurinol 100mg tablet

Allopurinol 300mg tablet
2 Kolsisin 0,5mg tablet

12
 • GOLONGAN UTEROTONIK, RELAKSAN UTERUS DAN OBAT
GYNEKOLOG LAIN

1 Metylergometrin 125mcg
2 Metylergometrin 200mcg/ml
3 Oksitosin 0,2mg/ml
4 Isoksuprin hcl 20mg/tablet Hystolan tablet
Isoksuprin hcl injeksi Proterin injeksi
5 Progesteron 100mg Microgest 100mg kapsul
6 Clomiphen Sitrat 50mg
7 Siproteron 2mg Diane tablet
8 Allylestrenol 5 mg
9 Noretisteron 5mg Norelut tablet
Norestil
10 Etynilestradiol 0,03mg Microgynon tablet
• GOLONGAN NARKOTIK

1 Codein 10mg tablet Codicaf 10mg tablet

Codein 20mg tablet Codicaf 20mg tablet
2 Morphine 19 mg tablet MST tablet
3 Pethidin 50mg/ml injeksi
Fentanyl 0,05mg /ml inj
4 Morfine injeksi
• GOLONGAN OBAT PROSTAT

1 Tamsulosin 0.2 mg tab

2 Tamsulosin 0.4 mg tab
3 Dutasteride 0,5 mg
• GOLONGAN OBAT MATA

1 Oxymetazoline HCL Cendo Astenof

2 Ofloxacin Cendo Floxa
3 Sodium Chlorid, Potassium Chloride Cendo Lyteers
Cendo Cenfresh
4 Kalium Iodide 5 mg Cendo Catarlent
5 Sodium Hialuronat 1 mg Cendo Hyalub
6 Levofloxacin eye drop
7 Timolol maleat 0.5 % isotic
8 Dexametason, Neomycin sulfate,
poliymyxin B Sulfate
Polidemicin Eye drop
9 Tobrammycin 3mg, Dexametason 1 mg Cendo Tobroson
10 Tetracaine Cendo pantocain 0.5%
11 Potasium iodide 5mg, Sodium Iodide 10 mg Cendo vitrolenta
12 Cloramphenicol Reco Tetes mata
Reco salep mata

13
13 Tropicamide 10 mg Cendo Mydriatil 1%
14 Gentamicin Genoin salep mata
Genoin tetes mata
Cendo Genta
15 Natrium diklofenak Cendo Noncort
Flamar eye drop
16 Vit. A palmitat, Zink Sulfat, Phenylephrine Cendo Augentonic
17 Sodium Chloride Cendo siloxan
18 Neomicin sulfat 3,5 mg, polimixin B sulfate, Cendo statrol
Fenilerin HCL
19 Antazoline Hcl, Naphazoline Hcl Cendo Vasacon
20 Phenylephrine / fenilefrin Hcl Cendo Efrisel
21 Homatropin Hbr 2 % Cendo Homatro
22 Atropine sulfate 1 % Cendo tropin

14