Sei sulla pagina 1di 185

Rekapitulasi Pengajuan Tagihan

Peserta
RJTL
No.
1

No Ka Peserta

Nama

0001423361586 P YUK AMALIA

Tanggal Pelayanan :

01 Januari 2016

Nama PPK :

IF RSUD PAMEKASAN

No
Rsp

Tgl Pel

s/d

Nama Obat

00007 02/01/2016 Metformin 500 mg

0001451727753 P FALALAH

0001048518292 P TITIK WAHYUNI

0000775990506 P HATIB

6.624,00

23

12.835,84

23

16.574,72

Propranolol 10 mg

46

3.827,20

00011 02/01/2016 Metformin 500 mg

46

6.624,00

23

12.835,84

23

4.357,12

23

5.505,28

00008 02/01/2016 Thyrozol 5 mg

00012 02/01/2016 Miniaspi 80 mg


Amlodipine 5 mg

0000117029597 P ABD HADI

0000098253459 P SUATUN

0000116900245 I SUHENAH

Harga
Obat

46

Glimepiride 2 mg
4

Jml
R/N Obt
N

Glimepiride 2 mg
2

02 Mei 2016

00015 02/01/2016 Lantus Solostar Pen 100 IU/ml

1 107.100,00

Novo Rapid FlexPen 100 IU/ml

1 107.534,70

Harga
Diajukan
19.460

20.402

19.460

9.862

214.635

00016 02/01/2016 Metformin 500 mg

69

9.936,00

Simvastatin 10 mg

23

4.975,36

Glucodex 80 mg

23

6.947,84

Amlodipine 10 mg

23

9.715,20

00017 02/01/2016 Metformin 500 mg

69

9.936,00

Amlodipine 5 mg

23

5.505,28

Ramipril 5 mg

23

17.075,20

69

21.638,40

21.638

31.574

32.516

0000117484817 P NOR AHMAD

00025 02/01/2016 Carbamazepine 200 mg

0000116983607 P JUNAIDI

00026 02/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

10

0001080071234 I NASIYAH

00027 02/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

11

0001874550014 P SULALAH

00029 02/01/2016 Allopurinol 100 mg

2.531,84

217.167

Lantus Solostar Pen 100 IU/ml

1 107.100,00

Novo Rapid FlexPen 100 IU/ml

1 107.534,70
1 142.799,58

142.800

9.936,00

32.310

12

0000116986465 P SITTI NURJANNAH

00031 02/01/2016 Seretide Diskus 250 250 mcg/puff

13

0001298658543 P SUMNA

00043 04/01/2016 Metformin 500 mg

Halaman :

23

69

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Glimepiride 4 mg

23

12.659,20

Amlodipine 10 mg

23

9.715,20

Harga
Diajukan

14

0001048545922 P FERI ANGGA RIAWAN

00044 04/01/2016 Carbamazepine 200 mg

69

21.638,40

21.638

15

0000117079659 P DJIMRON HARDIANTO

00049 04/01/2016 Allopurinol 100 mg

23

2.531,84

37.830

Amlodipine 10 mg

23

9.715,20

Gemfibrozil 300 mg

23

8.508,16

Ramipril 5 mg

23

17.075,20

16

0000779204272 P SUHRANTO

00050 04/01/2016 Amlodipine 5 mg

23

5.505,28

5.505

17

0001787915316 P SUPARLAN

00051 04/01/2016 Trifluoperazin 5 mg

23

11.923,20

18.547

23

6.624,00

Klorpromazin 100 mg
18

0000116935661 P H. ABDUL MUGID

00060 04/01/2016 Glimepiride 3 mg

23

11.893,76

11.894

19

0001836877713 P SUHAIMAH

00061 04/01/2016 Glimepiride 4 mg

23

12.659,20

90.940

Amlodipine 10 mg

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

Akarbose 100 mg

46

58.291,20

Furosemide 40 mg

23

2.502,40

00062 04/01/2016 Metformin 500 mg

69

9.936,00

Allopurinol 300 mg

23

5.873,28

Glibenklamide 5 mg

23

1.648,64

Fenofibrate 100 mg

23

31.648,00

Digoksin 0,25 mg

23

2.855,68

Furosemide 40 mg

23

2.502,40

Seretide Diskus 250 250 mcg/puff

20

0000116958341 P R.ACH.MASJKUR KAMIL

197.264

1 142.799,58

21

0000777981363 P TUMYANI

00063 04/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

22

0000117017785 P ABD RAHMAN

00064 04/01/2016 Glimepiride 2 mg

23

12.835,84

12.836

23

0001541229445 P BUDIMAN OENTUNG

00066 04/01/2016 Glimepiride 3 mg

23

11.893,76

11.894

24

0000116973742 P SITI DJUHRIYAH

00075 04/01/2016 Glucodex 80 mg

23

6.947,84

208.023

Amlodipine 10 mg

23

9.715,20

Micardis 80 mg

23 191.360,00

Halaman :

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

25

0000769858097 P SA RIYAH

00078 04/01/2016 Ventolin inhaler 100 mcg/puff

80.325,00

80.325

26

0000116828515 I FARIDATUL JANNAH

00079 04/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

27

0000770165875 P SAFI UDDIN

00080 04/01/2016 Phenytoin 100 mg

69

11.746,56

11.747

28

0000117081606 I SITI HAMIDAH

00081 04/01/2016 Miniaspi 80 mg

23

4.357,12

4.357

29

0000775783934 P MAE

00082 04/01/2016 Vitamin - B Complex komb

23

3.150,08

9.023

R.01 34,5

5.873,28

Nama

Tgl Pel

Nama Obat

Phenytoin 100 mg
30

31

32

0000775235182 P ROMILAH

0000116952041 P MOHAMAD DRADJID

0000775526951 P NATIFAH

00083 04/01/2016 Lantus Solostar Pen 100 IU/ml

1 107.100,00

Novo Rapid FlexPen 100 IU/ml

2 215.069,40

23 408.252,43

Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

23

16.574,72

69

5.740,80

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

23

9.273,60

23

2.502,40

23

29.822,72

Metformin 500 mg

69

9.936,00

Allopurinol 300 mg

23

5.873,28

Glimepiride 2 mg

23

12.835,84

00093 04/01/2016 Glimepiride 4 mg

23

12.659,20

23

17.075,20

69

9.936,00

23

12.659,20

00084 04/01/2016 Spiriva Refill 18 mcg

00085 04/01/2016 Thyrozol 5 mg


Propranolol 10 mg

33

34

0001443194379 P TIHANA

0001339414413 P ATNA

00086 04/01/2016 Isosorbid Dinitrat 5 mg

00087 04/01/2016 Spironolacton 25 mg


Furosemide 40 mg

35

36

0001100805759 P DWI ENGGAL


SULISTYORINI

0001379620708 P SILVANA TANI

00088 04/01/2016 Ramipril 10 mg

Ramipril 5 mg
37

0001429643103 P SUNA

00105 04/01/2016 Metformin 500 mg


Glimepiride 4 mg

322.169

435.632

22.316

23.905

11.776

58.468

29.734

22.595

38

0001315837348 P MOSLEH

00106 04/01/2016 Miniaspi 80 mg

23

4.357,12

4.357

39

0000116946145 P MOELJADI

00107 04/01/2016 Micardis 80 mg

23 191.360,00

198.171

Halaman :

No.

40

No Ka Peserta

Nama

0000774203692 P HAMIDAH

No
Rsp

Tgl Pel

Nama Obat

0001309758546 P LUKMAN HAKIM

43

0001324008382 P ZURIYAH

0001282612871 P TONA

Harga
Diajukan

23

5.505,28

Furosemide 40 mg

12

1.305,60

00108 04/01/2016 Propranolol 10 mg

46

3.827,20

23

33.414,40

69

11.746,56

23

7.212,80

69

9.936,00

Akarbose 100 mg

46

58.291,20

Glucodex 80 mg

23

6.947,84

23

9.715,20

23

17.075,20

69

9.936,00

9.936

1 142.799,58

142.800

5.475,84

5.476

2 215.069,40

215.069
36.476

00109 04/01/2016 Phenytoin 100 mg


Carbamazepine 200 mg

42

Harga
Obat

Amlodipine 5 mg

Thyrozol 10 mg
41

Jml
R/N Obt

00110 04/01/2016 Metformin 500 mg

00113 04/01/2016 Amlodipine 10 mg


Ramipril 5 mg

37.242

18.959

75.175

26.790

44

0001306752748 P LATIFAH

00121 04/01/2016 Metformin 500 mg

45

0000116986342 P SITI NURHAYATI

00122 04/01/2016 Seretide Diskus 250 250 mcg/puff

46

0001958995012 P H.RUSYDI

00127 04/01/2016 Captopril 12,5 mg

47

0001275777459 P SRI HAMIZEH

00128 04/01/2016 Novo Rapid FlexPen 100 IU/ml

48

0001048545955 P LENI IRAWATI

00152 05/01/2016 Bisoprolol 5 mg

23

18.988,80

Amlodipine 10 mg

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

69

9.936,00

Akarbose 100 mg

46

58.291,20

Glucodex 80 mg

46

13.895,68

Ramipril 5 mg

23

17.075,20

69

11.746,56

11.747

1 127.049,58

127.050
40.833

49

0000116926637 P ABD.KADIR

00170 05/01/2016 Metformin 500 mg

69

50

0001410409552 P INDAH LESTARI K

00176 05/01/2016 Phenytoin 100 mg

51

0001283708755 P KAMILIYAH

00181 05/01/2016 Seretide Diskus 100 100 mcg/puff

52

0000114937323 P ACHMAD SURJANTO

00184 05/01/2016 Isosorbid Dinitrat 5 mg

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

69

11.746,56

53

0000777728834 P IDA WATI

Halaman :

00185 05/01/2016 Phenytoin 100 mg

99.198

11.747

No.

No Ka Peserta

54

0000173117665 I RISKIATIN

Nama

No
Rsp

Tgl Pel

Nama Obat

00190 05/01/2016 Glimepiride 3 mg


Ramipril 5 mg

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

23

11.893,76

28.969

23

17.075,20

23

33.414,40

33.414

55

0001479470275 P SUMIATI

00191 05/01/2016 Thyrozol 10 mg

56

0000116912676 P MOH.ALI NITISASTRO

00198 05/01/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

57

0001322380585 P DEWI IRAWATI

00201 05/01/2016 Symbicort 80/4.5mcg

1 139.230,00

139.230

58

0000203035138 I SITI NAWARAH

00205 05/01/2016 Spironolacton 25 mg

23

9.273,60

28.851

Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

23

17.075,20

59

0001410109468 P ABD.RAHEM RH.

00206 05/01/2016 Captopril 25 mg

46

4.945,92

4.946

60

0001390264694 P MARYANI

00220 05/01/2016 Glimepiride 2 mg

23

12.835,84

22.551

Amlodipine 10 mg

23

9.715,20

00221 05/01/2016 Amlodipine 10 mg

23

9.715,20

23

12.835,84

61

0001271100789 P MAIMUNAH

Glimepiride 2 mg
62

0001476568686 P SADIEH

00222 05/01/2016 Lantus Solostar Pen 100 IU/ml

2 214.200,00

Novo Rapid FlexPen 100 IU/ml

6 645.208,20

Diovan 80 mg

23 114.816,00

Amlodipine 10 mg

23

9.715,20

Miniaspi 80 mg

23

4.357,12

63

0001265208581 P NINING INDRIAWATI

00225 05/01/2016 Seretide Diskus 100 100 mcg/puff

64

0000779511464 P SUGIANTO

00227 05/01/2016 Furosemide 40 mg

Ramipril 5 mg
Miniaspi 80 mg

22.551

988.297

1 127.049,58

127.050

23

2.502,40

23.935

23

17.075,20

23

4.357,12

65

0000776132921 P ABDUL MUKRAM

00230 05/01/2016 Glimepiride 3 mg

23

11.893,76

11.894

66

0001845099123 P DURRIYAH

00231 05/01/2016 Metformin 500 mg

69

9.936,00

29.249

Glimepiride 3 mg

23

11.893,76

Captopril 25 mg

69

7.418,88

00233 05/01/2016 Glimepiride 1 mg

23

7.801,60

7.802

00235 05/01/2016 Glucodex 80 mg

23

6.947,84

9.450

23

2.502,40

67
68

0000116982077 P DRS.EC.EFENDI
SUTRISNO, MM
0001877115115 P LILIK SURYANI

Furosemide 40 mg

Halaman :

No.

No Ka Peserta

69

0001881531573 P A.JALALUDDIN

Nama

No
Rsp

Tgl Pel

Nama Obat

00240 05/01/2016 Furosemide 40 mg

71

72

0000116932904 P DR.HANDOJO,MPH

0000116982573 P FATIMAH FANKIYAH

0001276375948 P MAIMUN

Harga
Obat

23

23 191.360,00

23

91.264,00

Amlodipine 5 mg

23

5.505,28

Foransi 10 10 mg

23

12.335,36

23 189.888,00

Foransi 10 10 mg

23

12.335,36

00257 05/01/2016 Glimepiride 1 mg

23

7.801,60

Metformin 500 mg

69

9.936,00

69

11.746,56

11.747

00241 05/01/2016 Candesartan Cilexetil 8 mg

00242 05/01/2016 Olandoz 5 5 mg

2.502,40

Harga
Diajukan

Micardis 80 mg
70

Jml
R/N Obt

193.862

109.105

202.223

17.738

73

0001801424766 P NOVA RISKIYAH

00262 06/01/2016 Phenytoin 100 mg

74

0000775698221 P SUMIH

00264 06/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

75

0000116833318 P M. SAJURI

00273 06/01/2016 Lantus Solostar Pen 100 IU/ml

1 107.100,00

117.036

76

0000117016132 P SUNDARI

Metformin 500 mg

69

9.936,00

00276 06/01/2016 Vitamin B6 10 mg

23

1.766,40

23

4.357,12

Miniaspi 80 mg

6.124

77

0000116984193 P MAZHAR

00277 06/01/2016 Diovan 80 mg

23 114.816,00

114.816

78

0001410410261 P HANIYAH

00291 06/01/2016 Metformin 500 mg

69

9.936,00

30.014

Glimepiride 4 mg

23

12.659,20

Captopril 25 mg

69

7.418,88

00292 06/01/2016 Captopril 25 mg

69

7.418,88

79

0001304829246 P AMIN FAIZ

Lantus Solostar Pen 100 IU/ml

1 107.100,00

Novo Rapid FlexPen 100 IU/ml

2 215.069,40

Miniaspi 80 mg

23

4.357,12

333.945

80

0001048324285 P M.YUNUS

00293 06/01/2016 Glimepiride 4 mg

23

12.659,20

12.659

81

0001427443132 P AINUR RIDWAN

00294 06/01/2016 Kalipar 300 mg

23

20.608,00

23.110

Furosemide 40 mg

23

2.502,40

00295 06/01/2016 Metformin 500 mg

69

9.936,00

23 191.360,00

69

82

0000777427301 P SAFATUN

Micardis 80 mg
83

0000116984744 P MOJIONO

Halaman :

00308 06/01/2016 Metformin 500 mg

9.936,00

201.296

22.595

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Glimepiride 4 mg

23

12.659,20

Harga
Diajukan

84

0000117050062 P MOH SJAIFUL EFENDI

00309 06/01/2016 Glimepiride 4 mg

23

12.659,20

12.659

85

0001082445546 P SRIYATI

00310 06/01/2016 Miniaspi 80 mg

23

4.357,12

31.118

Isosorbid Dinitrat 5 mg

69

7.772,16

Bisoprolol 5 mg

23

18.988,80

86

0000774338286 P NUR JANNAH

00311 06/01/2016 Thyrozol 5 mg

23

16.574,72

16.575

87

0001292977056 P FATHOR RAHMAN

00312 06/01/2016 Metformin 500 mg

69

9.936,00

31.573

Amlodipine 5 mg

23

5.505,28

Glimepiride 3 mg

23

11.893,76

Lansoprazole 30 mg

4.238,08

00313 06/01/2016 Lansoprazole 30 mg

4.238,08

23

12.835,84

23

3.312,00

23

8.508,16

88

0000116988039 P ZAINAL ARIFIN

Glimepiride 2 mg
89

0000116991483 P ABD WAFI

00324 06/01/2016 Metformin 500 mg


Gemfibrozil 300 mg

90

0001266925847 P MOH.MANSUR

00325 06/01/2016 Novo Rapid FlexPen 100 IU/ml

91

0000777983501 P FAISAL

00327 06/01/2016 Vitamin B6 10 mg

Bisoprolol 5 mg
Amlodipine 10 mg
92

93

94

0000117021082 P ABDUL MAHWAR

0000117071087 P RUDY SETIAWAN

0000116673221 P SITI KIPIYAH

00328 06/01/2016 Micardis 80 mg

0000202346032 P SAKDIJAH

1.766,40

30.470

23

18.988,80

23

9.715,20

23 191.360,00
4.238,08

Miniaspi 80 mg

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

11

3.280,64

Olandoz 10 10 mg

11 157.696,00

Risperidon 2 mg

23

29.675,52

23

4.239,36

11

70.400,00

23

39.479,04

23

6.859,52

00348 07/01/2016 Merlopam 2 mg


Alprazolam 1 mg

Halaman :

23

Clorilex 100 100 mg


95

322.604

00346 07/01/2016 Klorpromazin 100 mg

11.820

3 322.604,10

Lansoprazole 30 mg

00344 07/01/2016 Alprazolam 1 mg

17.074

207.727

190.652

74.639

376.067

No.

96

97

No Ka Peserta

Nama

0000147812038 P ABU HASAN, A.PRA.TTD

0000116559944 P MUHAMAD TRISWARNO

No
Rsp

Tgl Pel

Nama Obat

0000773198537 P AGUS MULYADI

100

23 329.728,00

00349 07/01/2016 Allopurinol 300 mg

23

5.873,28

Lisinopril 10 mg

23

17.664,00

Amlodipine 10 mg

23

9.715,20

11

1.576,96

11

3.013,12

138

56.348,16

34

4.656,64

16 133.120,00

Isosorbid Dinitrat 5 mg

69

7.772,16

Miniaspi 80 mg

23

4.357,12

00354 07/01/2016 Miniaspi 80 mg

23

4.357,12

69

7.772,16

00355 07/01/2016 Concor 2,5 mg

23

21.962,24

Micardis 80 mg

16 133.120,00
1 127.049,58

127.050
19.064

00350 07/01/2016 Amitriptyline 25 mg

00351 07/01/2016 Propiltiourasil 100 mg

0000116891177 P SULIMAH JD SAROEDJI 00352 07/01/2016 Micardis 80 mg

0001855284208 P HOLILAH

Isosorbid Dinitrat 5 mg
101

0000208493886 I HAMIDAH

102

0000117130421 P SUPARMAN

00358 07/01/2016 Seretide Diskus 100 100 mcg/puff

103

0000774216358 P MASRIFAH

00359 07/01/2016 Vitamin - B Complex komb

23

3.150,08

Alprazolam 1 mg

12

3.578,88

Foransi 10 10 mg

23

12.335,36

69

9.936,00

23

12.659,20

38.400,00

Depakote ER 250 mg

23

82.225,92

Risperidon 2 mg

46

59.351,04

104

0000777931683 P ABD.KARIM

00361 07/01/2016 Metformin 500 mg


Glimepiride 4 mg

105

0001133529107 P EKA SUSAN PRIANTO

00362 07/01/2016 Clorilex 100 100 mg

106

0000116878162 P SUPRAPTI

00367 07/01/2016 Seretide Diskus 250 250 mcg/puff

107

0000195147404 I MARWATI

00369 07/01/2016 Lisinopril 10 mg

N
N

Amlodipine 10 mg
108

0000116833961 P MOH MAKSUM

00370 07/01/2016 Seretide Diskus 250 250 mcg/puff

109

0000117130432 I KUSMIATI ADRAI

00371 07/01/2016 Allopurinol 300 mg

Halaman :

Harga
Diajukan

Propranolol 40 mg
99

Harga
Obat

Olandoz 10 10 mg

Alprazolam 0,5 mg
98

Jml
R/N Obt

33.252

4.590

61.005

145.249

12.129

155.082

22.595

179.977

1 142.799,58

142.800

23

17.664,00

27.379

23

9.715,20

1 142.799,58

142.800

5.873,28

5.873

23

No.

No Ka Peserta

110

0001318111604 P RIA TRIDIBINA

Nama

No
Rsp

Tgl Pel

Nama Obat

00372 07/01/2016 Amitriptyline 25 mg

Jml
R/N Obt

Harga
Obat

23

3.297,28

Alprazolam 0,5 mg

23

6.300,16

Risperidon 1 mg

46

70.656,00

Harga
Diajukan
80.253

111

0000775311671 P SUSMIYATI

00373 07/01/2016 Glimepiride 3 mg

23

11.893,76

11.894

112

0001313006264 P SUDARSO

00375 07/01/2016 Glimepiride 3 mg

23

11.893,76

216.689

Micardis 80 mg

23 191.360,00

Isosorbid Dinitrat 5 mg

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Furosemide 40 mg

12

1.305,60

113

114

0000116985284 I SAMSITI

0001094091748 P ABD.KARIM

00382 07/01/2016 Lantus Solostar Pen 100 IU/ml

1 107.100,00

Novo Rapid FlexPen 100 IU/ml

2 215.069,40

23 170.752,00

23 209.024,00

00384 07/01/2016 Harnal D 0,2 mg


Avodart 0,5 mg

115

116

0000117124547 P RUKIYATUN
KUSDWITANTY

0000777097304 P KIBTIYAH

00385 07/01/2016 Berotec MDI 100 mcg/puff

91.854,00

Miniaspi 80 mg

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Bisoprolol 5 mg

23

18.988,80

23

1.913,60

23

33.414,40

00390 07/01/2016 Propranolol 10 mg


Thyrozol 10 mg

117

0000174063047 I SHOFIAH

00397 07/01/2016 Seretide Diskus 250 250 mcg/puff

118

0000116951872 I NURHASANAH

00400 07/01/2016 Metformin 500 mg

Allopurinol 300 mg

119

0000116998615 P MOCH NAWAWI

322.169

379.776

122.972

35.328

1 142.799,58

142.800

23

3.312,00

60.146

23

5.873,28

Captopril 25 mg

69

7.418,88

Fenofibrate 100 mg

23

31.648,00

Glimepiride 3 mg

23

11.893,76

46

4.945,92

23

2.502,40

00402 07/01/2016 Captopril 25 mg


Furosemide 40 mg

7.448

120

0001048494014 P DJUNA

00404 07/01/2016 Captopril 25 mg

46

4.945,92

4.946

121

0001295565377 P SIRAD

00408 07/01/2016 Spironolacton 25 mg

23

9.273,60

184.092

Halaman :

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

12

8.908,80

Seretide Diskus 250 250 mcg/puff

Kalipar 300 mg

23

20.608,00

23

33.414,40

33.414

1 142.799,58

122

0001318125262 P NURUL ANISYAH

00423 08/01/2016 Thyrozol 10 mg

123

0001297237724 P MOH.ZAINI IHKSAN

00436 08/01/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

124

0000117061784 P MOH SUGIANTO

00441 08/01/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

125

0000116984709 P MOHAMMAD RIDA`I

00442 08/01/2016 Gemfibrozil 300 mg

23

8.508,16

18.223

23

9.715,20

23

2.060,80

Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

00445 08/01/2016 Lisinopril 10 mg

23

17.664,00

Gemfibrozil 300 mg

23

8.508,16

Amlodipine 10 mg

23

9.715,20

23

17.664,00

17.664

1 107.100,00

473.069

Amlodipine 10 mg
126

127

0000116986509 P SITTI ROKAYYAH NASIR 00443 08/01/2016 Kalsium Laktat 500 mg

0001960351187 P RUSLAN MULYADI

128

0001443797291 P MUTMAINNAH

00451 08/01/2016 Lisinopril 10 mg

129

0000116675752 P MUKTIYAH

00452 08/01/2016 Lantus Solostar Pen 100 IU/ml

130

0000775541856 P DULLA

Bisoprolol 5 mg

23

18.988,80

Amlodipine 10 mg

23

9.715,20

Miniaspi 80 mg

23

4.357,12

Novo Rapid FlexPen 100 IU/ml

Lisinopril 5 mg

23

10.304,00

46

3.827,20

138

56.348,16

00456 09/01/2016 Propranolol 10 mg


Propiltiourasil 100 mg

29.440

35.887

3 322.604,10

60.175

131

0001385196142 P TEDI RIAN HANDIKA

00462 09/01/2016 Phenytoin 100 mg

69

11.746,56

11.747

132

0000775628436 P MUSARROFAH

00469 09/01/2016 Propranolol 10 mg

69

5.740,80

72.570

46

66.828,80

Thyrozol 10 mg
133

0000775128879 P MOTRO

00471 09/01/2016 Stalevo 325 mg komb

46 524.032,00

524.032

134

0001795802398 P FAJARIYAH MULYANI

00473 09/01/2016 Micardis 40 mg

23 114.816,00

244.264

Halaman :

10

No.

135

136

137

No Ka Peserta

Nama

0000773996837 P SUNARYA

0000117029485 I ROFIATUS SYARIFAH

0000117495909 P SALIM B HUBAIS

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Bisoprolol 5 mg

23

Herbesser CD 100 mg

23 107.956,48

Furosemide 40 mg

23

2.502,40

00474 09/01/2016 Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

Akarbose 100 mg

46

58.291,20

Lisinopril 10 mg

23

17.664,00

69

9.936,00

Glimepiride 3 mg

23

11.893,76

Amlodipine 10 mg

23

9.715,20

00480 09/01/2016 Metformin 500 mg

00486 09/01/2016 Lantus Solostar Pen 100 IU/ml

Harga
Diajukan

18.988,80

1 107.100,00

Miniaspi 80 mg

23

Clopidogrel 75 mg

23 100.096,00

Novo Rapid FlexPen 100 IU/ml

2 215.069,40

98.550

31.545

426.623

4.357,12

138

0000116734206 P HASYIRULLAH

00490 09/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

139

0000772624089 P PUSIHA

00491 09/01/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

140

0000172609029 1 ABDUR ROHMAN

00492 09/01/2016 Gemfibrozil 300 mg

23

8.508,16

8.508

141

0000117369617 P ACHMAD AS'AD

00493 09/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

142

0000116984305 P MISKI

00496 09/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

143

0001048521521 P HADIRI

00500 09/01/2016 Metformin 500 mg

69

9.936,00

22.772

23

12.835,84

Glimepiride 2 mg
144

0000198713158 I SALIMAH

00501 09/01/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

145

0001410845848 P HARIS BURHAN

00502 09/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

146

0000114179962 P ABD. KAHIR

00503 09/01/2016 Metformin 500 mg

69

9.936,00

22.595

Glimepiride 4 mg

23

12.659,20

147

0001908165789 P ASIYAH

00504 09/01/2016 Glimepiride 3 mg

23

11.893,76

11.894

148

0000099722092 P KASMAN

00505 09/01/2016 Lisinopril 10 mg

23

17.664,00

27.026

Miniaspi 80 mg

23

4.357,12

Furosemide 40 mg

46

5.004,80

Halaman :

11

No.

No Ka Peserta

149

0001895351286 P MOH.HASAN

Nama

No
Rsp

Tgl Pel

Nama Obat

00508 09/01/2016 Klorpromazin 100 mg

151

152

153

154

0001195095767 P INTAN RAHMAWATI

0000116934917 P FADLI

0000117044616 P MOHAMAD RIFAI

0000774626253 P MASSORI

0001282144184 P JUMA'I

Harga
Obat

46

13.248,00

46

5.652,48

00509 09/01/2016 Amitriptyline 25 mg

23

3.297,28

Haloperidol 0,5 mg

46

3.473,92

Alprazolam 0,5 mg

23

6.300,16

46 164.451,84

Alprazolam 1 mg

23

6.859,52

Clorilex 100 100 mg

12

76.800,00

Haloperidol 5 mg
150

Jml
R/N Obt

00518 09/01/2016 Depakote ER 250 mg

00520 09/01/2016 Lantus Solostar Pen 100 IU/ml

1 107.100,00

Novo Rapid FlexPen 100 IU/ml

2 215.069,40

00522 09/01/2016 Allopurinol 300 mg

23

5.873,28

Furosemide 40 mg

12

1.305,60

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

00528 11/01/2016 Isosorbid Dinitrat 5 mg

Harga
Diajukan
18.900

13.071

248.111

322.169

7.179

21.844

155

0001542296575 P SHALEHATUN

00530 11/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

156

0001823203765 P MOH.SHOLEH

00533 11/01/2016 Isosorbid Dinitrat 5 mg

69

7.772,16

14.632

Miniaspi 80 mg

23

4.357,12

Furosemide 40 mg

23

2.502,40

157

0001808030057 P HAIRUL MUSTAJAB

00539 11/01/2016 Glimepiride 4 mg

23

12.659,20

12.659

158

0001958647331 P MARWANI

00540 11/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

159

0000117197436 I SULASMI

00542 11/01/2016 Candesartan Cilexetil 8 mg

23

91.264,00

112.902

69

21.638,40

23

2.531,84

Glimepiride 1 mg

23

7.801,60

Captopril 25 mg

69

7.418,88

Gemfibrozil 300 mg

23

8.508,16

46

58.291,20

46

13.895,68

Carbamazepine 200 mg
160

161

0001268974517 P LIMRIATIN

0000117122962 P A SUGIANTO

00544 11/01/2016 Allopurinol 100 mg

00545 11/01/2016 Akarbose 100 mg


Glucodex 80 mg

Halaman :

12

26.260

82.123

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Metformin 500 mg

162

0000775228105 P FADILAH

0001894864252 P MUAYYAH

69

9.936,00

46

33.149,44

69

5.740,80

23

16.574,72

23

9.715,20

23

91.264,00

23

9.715,20

23

91.264,00

Clorilex 100 100 mg

46 294.400,00

Amitriptyline 25 mg

46

00547 11/01/2016 Thyrozol 5 mg

00552 11/01/2016 Thyrozol 5 mg


Amlodipine 10 mg

164

0000116902923 I MARYAMAH

00553 11/01/2016 Candesartan Cilexetil 8 mg


Amlodipine 10 mg

165

0000117217618 P KUTSIJAH

Harga
Obat

Propranolol 10 mg
163

Jml
R/N Obt

00554 11/01/2016 Candesartan Cilexetil 8 mg

Harga
Diajukan

38.890

26.290

100.979

392.259

6.594,56

166

0001435075187 P ARIDA LUTHFIYANA

00556 11/01/2016 Diovan 80 mg

23 114.816,00

114.816

167

00559 11/01/2016 Bisoprolol 5 mg

23

18.988,80

18.989

168

0000116798567 I DEWI
ANGGRAYININGSIH, ST
0001389542163 P ELLY FRIAH NINGSIH

00561 11/01/2016 Amlodipine 5 mg

23

5.505,28

5.505

169

0000116722168 I S. HOLIFAH

00566 11/01/2016 Glimepiride 3 mg

23

11.893,76

11.894

170

0000142684119 P DJOKO WIDODO

00573 11/01/2016 Simvastatin 10 mg

23

4.975,36

26.805

Metformin 500 mg

69

9.936,00

Glimepiride 3 mg

23

11.893,76

23

9.715,20

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

171

172

0001453212156 P FAISOL

0000117126887 P ASTUTIK

00583 11/01/2016 Amlodipine 10 mg

00584 11/01/2016 Lantus Solostar Pen 100 IU/ml

2 214.200,00

Novo Rapid FlexPen 100 IU/ml

5 537.673,50

Amlodipine 10 mg

23

9.715,20

23

9.715,20

9.715

1 107.100,00

118.994

173

0000116834117 I HOSSIYAH

00586 11/01/2016 Amlodipine 10 mg

174

0000159890894 P RUMMINI

00595 11/01/2016 Lantus Solostar Pen 100 IU/ml

Glimepiride 3 mg
175

0001830612543 P SUNARWATI

00598 11/01/2016 Metformin 500 mg


Glimepiride 3 mg

176

0001795629317 P MUNAWAR

Halaman :

13

21.491

00599 11/01/2016 Spironolacton 25 mg

23

11.893,76

69

9.936,00

23

11.893,76

23

9.273,60

761.589

21.830

11.776

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Furosemide 40 mg

Jml
R/N Obt

Harga
Obat

23

2.502,40

Harga
Diajukan

177

0000775479273 P HOTIMAH

00600 11/01/2016 Thyrozol 10 mg

23

33.414,40

33.414

178

0000116698601 P MANDAT

00601 11/01/2016 Metformin 500 mg

69

9.936,00

22.595

23

12.659,20

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Ramipril 5 mg

23

17.075,20

Glimepiride 4 mg
179

180

0000774273238 P SUDARMAN

0000778262984 P SITTIHA

00602 11/01/2016 Amlodipine 10 mg

00603 11/01/2016 Lantus Solostar Pen 100 IU/ml

2 214.200,00

Novo Rapid FlexPen 100 IU/ml

6 645.208,20

181

0000775058253 P BAHRUD

00620 11/01/2016 Thyrozol 10 mg

182

0001279734884 P EKO MARDIONO

00621 11/01/2016 Seretide Diskus 250 250 mcg/puff

183

859.408

33.414,40

33.414

1 142.799,58

164.644

23

Miniaspi 80 mg

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Amlodipine 10 mg

23

9.715,20

23 408.252,43

23

9.273,60

Digoksin 0,25 mg

23

2.855,68

Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

23

17.075,20

0000117085948 P DRS. H. RAKHMAN AGUS 00622 11/01/2016 Spiriva Refill 18 mcg


KREATIEF
Spironolacton 25 mg

38.920

439.959

184

0000116991753 P MOHAMMAD JUFFRI

00632 12/01/2016 Glikuidon 30 mg

23

27.968,00

27.968

185

0000116945234 I KINAAH

00643 12/01/2016 Vitamin B6 10 mg

23

1.766,40

15.839

Amlodipine 10 mg

23

9.715,20

Miniaspi 80 mg

23

4.357,12

186
187
188

0000116824656 P RADEN HANAFI


HENDRAJANA
0000116986083 P SAMHUDI

00644 12/01/2016 Levopar 125 mg komb

69 132.480,00

132.480

00650 12/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

0000197467569 1 NURCHOLIS SETIAWAN


ALI

00652 12/01/2016 Carbamazepine 200 mg

23

7.212,80

16.369

Haloperidol 0,5 mg

46

3.473,92

Vitamin B6 10 mg

R.01

23

1.766,40

Halaman :

14

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Phenytoin 100 mg

189

0001048426053 P ROFIAH

00655 12/01/2016 Amlodipine 10 mg


Lisinopril 10 mg

Jml
R/N Obt

Harga
Obat

R.01

23

3.915,52

23

9.715,20

23

17.664,00

23

4.357,12

4.357
322.169

190

0000116984709 P MOHAMMAD RIDA`I

00659 12/01/2016 Miniaspi 80 mg

191

0001958995012 P H.RUSYDI

00663 12/01/2016 Lantus Solostar Pen 100 IU/ml

1 107.100,00

Novo Rapid FlexPen 100 IU/ml

2 215.069,40

192

0001048526212 P MUSIRAH

00666 12/01/2016 Vitamin B6 10 mg

23

1.766,40

23

4.357,12

23

1.766,40

23

4.357,12

69

9.936,00

Glimepiride 4 mg

23

12.659,20

Akarbose 100 mg

46

58.291,20

69

9.936,00

Glucodex 80 mg

46

13.895,68

Miniaspi 80 mg
193

0000117053155 P RATNOTO

00669 12/01/2016 Vitamin B6 10 mg


Miniaspi 80 mg

194

195

0000774275927 P SANIRAH

0000116906613 I SUPATYA

00670 12/01/2016 Metformin 500 mg

00673 12/01/2016 Metformin 500 mg

Harga
Diajukan

27.379

6.124

6.124

80.886

23.832

196

0000166549263 P EDDJU

00684 12/01/2016 Amlodipine 5 mg

23

5.505,28

5.505

197

0001311944365 P ATIYEH

00694 12/01/2016 Amlodipine 5 mg

23

5.505,28

8.008

23

2.502,40

Furosemide 40 mg
198

0001830962902 P HARUN SUYITNO

00699 12/01/2016 Seretide Diskus 250 250 mcg/puff

199

0000117370091 P H.MASJHURI

00700 12/01/2016 Captopril 25 mg

Metformin 500 mg
Glikuidon 30 mg
200

0000116852444 P SAHURI

201

000777979991

202

142.800

69

7.418,88

45.323

69

9.936,00

23

27.968,00

00705 12/01/2016 Lantus Solostar Pen 100 IU/ml

1 107.100,00

Novo Rapid FlexPen 100 IU/ml

3 322.604,10

429.704

00713 12/01/2016 Levopar 125 mg komb

46

88.320,00

88.320

0000776136407 P SITI HORIAH

00714 12/01/2016 Glimepiride 4 mg

23

12.659,20

12.659

203

0000117375952 I HJ.SUKASIZAH

00720 12/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

204

0000776336411 P HAMIDAH

00721 12/01/2016 Glimepiride 1 mg

23

7.801,60

7.802

205

0000116828943 P ABDULLAH, S.AG

00722 12/01/2016 Metformin 500 mg

69

9.936,00

123.574

Halaman :

15

P MUTAWI

1 142.799,58

No.

206

No Ka Peserta

Nama

0000116966046 I SITI ROCHANI

No
Rsp

Tgl Pel

Nama Obat

208

0001304457513 P JUMANI

0000116802551 I KARTININGSIH

23

12.659,20

Candesartan Cilexetil 8 mg

23

91.264,00

Amlodipine 10 mg

23

9.715,20

23

31.648,00

23

11.893,76

23 100.096,00

Seretide Diskus 250 250 mcg/puff

1 142.799,58

Bisoprolol 5 mg

23

18.988,80

Ramipril 5 mg

23

17.075,20

69

9.936,00

23

12.659,20

69

9.936,00

23

12.659,20

23

17.075,20

23

8.508,16

23

9.715,20

Micardis 80 mg

23 191.360,00

Furosemide 40 mg

23

2.502,40

00725 12/01/2016 Fenofibrate 100 mg

00727 12/01/2016 Clopidogrel 75 mg

00731 12/01/2016 Metformin 500 mg


Glimepiride 4 mg

209

0000199657225 I UMI SULCHAH

00733 12/01/2016 Metformin 500 mg


Glimepiride 4 mg

210

0000163662311 S MOH. SAHRI

00735 12/01/2016 Ramipril 5 mg


Gemfibrozil 300 mg

211

0000775906749 P MOH.SYAFIH

Harga
Obat

Glimepiride 4 mg

Glimepiride 3 mg
207

Jml
R/N Obt

00736 12/01/2016 Amlodipine 10 mg

Harga
Diajukan

43.542

278.960

22.595

22.595

25.583

203.578

212

0001868438158 P SRI LIESNURYATI

00737 12/01/2016 Ramipril 5 mg

23

17.075,20

17.075

213

0001895626462 P SUKARLANA

00738 12/01/2016 Ramipril 5 mg

23

17.075,20

25.583

23

8.508,16

69

9.936,00

46

13.895,68

69

5.740,80

23

33.414,40

23

9.715,20

23

17.075,20

Gemfibrozil 300 mg
214

0000049198522 I FATIMAH

00739 12/01/2016 Metformin 500 mg


Glucodex 80 mg

215

0001048377284 P HAZIZAH

00746 13/01/2016 Propranolol 10 mg


Thyrozol 10 mg

216

0000779796494 P K.ALAWI

00748 13/01/2016 Amlodipine 10 mg


Ramipril 5 mg

23.832

39.155

26.790

217

0000098230307 I SUMAIDAH

00769 13/01/2016 Micardis 80 mg

23 191.360,00

191.360

218

0001048397218 P SURAHMI

00770 13/01/2016 Metformin 500 mg

69

9.936,00

18.742

Halaman :

16

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Glimepiride 4 mg

219

0000776569184 P HOTIJA

00771 13/01/2016 Metformin 500 mg


Glimepiride 4 mg

Jml
R/N Obt

Harga
Obat

16

8.806,40

69

9.936,00

16

8.806,40

Harga
Diajukan

18.742

220

0000116941105 P KINAAH JD.SANAPI

00772 13/01/2016 Diovan 80 mg

23 114.816,00

114.816

221

0000094685084 I SRI SUNINGSIH

00773 13/01/2016 Lantus Solostar Pen 100 IU/ml

1 107.100,00

111.457

Miniaspi 80 mg
222

0000776141583 P ROHMATUSSOLIHAH

23

4.357,12

38.400,00

23

29.675,52

69

7.772,16

23

4.357,12

00789 13/01/2016 Metformin 500 mg

69

9.936,00

Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Lisinopril 10 mg

23

17.664,00

46

3.827,20

46

66.828,80

23

5.873,28

23

7.801,60

1 7.914.200,0
0
1 7.914.200,0
0
17.664,00
23

00780 13/01/2016 Clorilex 100 100 mg


Risperidon 2 mg

223

0001048463998 P ST.SULALAH

00788 13/01/2016 Isosorbid Dinitrat 5 mg


Miniaspi 80 mg

224

225

0000116883764 I KOESTINAH

0000773893991 P MARSUDAH

00791 13/01/2016 Propranolol 10 mg


Thyrozol 10 mg

226

0000116740348 P ABD SYAKUR

00793 13/01/2016 Allopurinol 300 mg


Glimepiride 1 mg

227

0000780212463 P ACH.SAUKI

00795 13/01/2016 Top Up Hemofilia RS B Reg I NULL

228

0000780402251 P AGUS

00796 13/01/2016 Top Up Hemofilia RS B Reg I NULL

229

0000117034301 P MARTINAH

00800 13/01/2016 Lisinopril 10 mg

Amlodipine 10 mg
230

231

0000117468898 P MOH SAHRAWI

0000117048767 P MARSUKI

00801 13/01/2016 Lantus Solostar Pen 100 IU/ml

1 107.100,00

Novo Rapid FlexPen 100 IU/ml

2 215.069,40

00804 13/01/2016 Amlodipine 10 mg

68.076

12.129

49.209

70.656

13.675

7.914.200
7.914.200
18.509

844,80

23

9.715,20

Lisinopril 10 mg

23

17.664,00

322.169

27.379

232

0000116977274 P ABOEBAKAR

00806 13/01/2016 Captopril 50 mg

45

8.064,00

8.064

233

0001963931207 P HOSNIYAH

00812 13/01/2016 Propranolol 10 mg

23

1.913,60

35.328

23

33.414,40

69

9.936,00

Thyrozol 10 mg
234

0000116937584 P HALIMAH

Halaman :

17

00813 13/01/2016 Metformin 500 mg

16.884

No.
234

No Ka Peserta
0000116937584 P

Nama
JD.ABD.RACHMAN

No
Rsp

Tgl Pel

Nama Obat

00813 13/01/2016 Metformin 500 mg


Glucodex 80 mg

235

0000117005556 P LUKMAN TAUFIK

00814 13/01/2016 Glimepiride 3 mg


Furosemide 40 mg

236

0000116970906 I SUNAYYA

00815 13/01/2016 Glimepiride 2 mg


Gemfibrozil 300 mg

237

238

0001870262943 P SANHAJI

0000117034727 I SITI RAODAH

240

241

242

0000776677522 P M RUJI

0001078173944 S AKHMAD EFFENDI

0000116940396 P JAJUK KUSTIRAHAYU

0000116963717 P SAUDI IDRIS

Harga
Obat

69

9.936,00

23

6.947,84

23

11.893,76

12

1.305,60

23

12.835,84

23

8.508,16

00817 13/01/2016 Lantus Solostar Pen 100 IU/ml

1 107.100,00

Novo Rapid FlexPen 100 IU/ml

4 430.138,80

00826 13/01/2016 Lisinopril 10 mg

23

17.664,00

23

11.893,76

00828 13/01/2016 Micardis 40 mg

23 114.816,00

Kalipar 300 mg

23

20.608,00

Furosemide 40 mg

23

2.502,40

23

91.264,00

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

Isosorbid Dinitrat 5 mg

46

5.181,44

Clopidogrel 75 mg

23 100.096,00

23

17.664,00

Miniaspi 80 mg

23

4.357,12

Lansoprazole 30 mg

23

13.925,12

Amlodipine 10 mg

1.267,20

1 107.100,00

Glimepiride 3 mg
239

Jml
R/N Obt

00829 13/01/2016 Candesartan Cilexetil 8 mg

00830 13/01/2016 Lisinopril 10 mg

00831 13/01/2016 Lantus Solostar Pen 100 IU/ml


Metformin 500 mg

69

9.936,00

Bisoprolol 5 mg

23

18.988,80

Lisinopril 10 mg

23

17.664,00

Harga
Diajukan

16.884

13.199

21.344

537.239

29.558

137.926

208.317

37.213

153.689

243

0000116971986 P ITUNIYATI

00832 13/01/2016 Captopril 25 mg

69

7.418,88

7.419

244

0000775640518 P MARTILA

00839 13/01/2016 Captopril 25 mg

69

7.418,88

7.419

245

0001410298762 P SUNIYAH

00840 13/01/2016 Lisinopril 10 mg

23

17.664,00

17.664

246

0001094833473 P BAMBANG RATMOKO

00841 13/01/2016 Miniaspi 80 mg

23

4.357,12

4.470

Halaman :

18

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Isosorbid Dinitrat 5 mg

Jml
R/N Obt

Harga
Obat

112,64

Harga
Diajukan

247

0001048339304 P MAS AH

00842 13/01/2016 Metformin 500 mg

69

9.936,00

9.936

248

0001410386534 P HARI

00843 13/01/2016 Miniaspi 80 mg

23

4.357,12

46.456

Kalipar 300 mg

23

20.608,00

Bisoprolol 5 mg

23

18.988,80

Furosemide 40 mg

23

2.502,40

00844 13/01/2016 Propranolol 10 mg

69

5.740,80

46

66.828,80

2.161,92

69

5.740,80

249

0000773783019 P KHOTIMATUS

Thyrozol 10 mg
250

0000775920802 P ROMLAH

00845 13/01/2016 Thyrozol 5 mg


Propranolol 10 mg

72.570

7.903

251

0001963895826 P SURYANI

00850 13/01/2016 Micardis 40 mg

23 114.816,00

114.816

252

0000117502031 P SLAMET RIYADI

00866 14/01/2016 Lisinopril 10 mg

23

17.664,00

17.664

253

0000116983528 P JUHAIRIYAH

00869 14/01/2016 Isosorbid Dinitrat 5 mg

69

7.772,16

12.129

23

4.357,12

Miniaspi 80 mg
254

0000775363781 P MOH.HARIRI

00880 14/01/2016 Thyrozol 5 mg

46

33.149,44

33.149

255

0000117062201 P SJAIFUL RACHMAD

00882 14/01/2016 Miniaspi 80 mg

23

4.357,12

12.129

69

7.772,16

23

4.357,12

11

1.196,80

Isosorbid Dinitrat 5 mg
256

0000774915941 P SUPATMA

00883 14/01/2016 Miniaspi 80 mg


Furosemide 40 mg

257

0000116985115 P H.N. SUGIARTO

00884 14/01/2016 Seretide Diskus 250 250 mcg/puff

258

0000116985126 I SUTJI AMINGSIH

00885 14/01/2016 Allopurinol 100 mg

Glucodex 80 mg

259

0001429868812 P SUBAIRI

Halaman :

19

5.554

1 142.799,58

142.800

23

2.531,84

25.289

23

6.947,84

Amlodipine 5 mg

23

5.505,28

Lisinopril 5 mg

23

10.304,00

12

1.305,60

Lisinopril 10 mg

23

17.664,00

Miniaspi 80 mg

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Amlodipine 10 mg

23

9.715,20

00886 14/01/2016 Furosemide 40 mg

40.814

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

260

0000116910382 P MARTA'I

00887 14/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

261

0000116958802 P R.M.ISKANDAR
MIFTAH,SH

00889 14/01/2016 Micardis 40 mg

23 114.816,00

148.598

Glikuidon 30 mg

23

27.968,00

Metformin 850 mg

23

5.814,40

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Furosemide 40 mg

23

2.502,40

262

Nama

0000116922273 P MOH. SUBAIDI

Tgl Pel

Nama Obat

00889 14/01/2016 Isosorbid Dinitrat 5 mg

14.632

263

0000117516161 P SUSI AGUSTIN, AMA.PD

00890 14/01/2016 Allopurinol 300 mg

23

5.873,28

5.873

264

0000779204272 P SUHRANTO

00897 14/01/2016 Propranolol 40 mg

34

4.656,64

8.895

4.238,08

Lansoprazole 30 mg
265

0000116824509 P NURHASAN

00898 14/01/2016 Micardis 40 mg

23 114.816,00

Fenofibrate 100 mg

23

31.648,00

Glimepiride 2 mg

23

12.835,84

159.300

266

0000116958813 I DRA.AGUSTINA

00901 14/01/2016 Micardis 40 mg

23 114.816,00

114.816

267

0000778901962 P SUBAIDAH

00902 14/01/2016 Captopril 50 mg

69

12.364,80

12.365

268

0001895351286 P MOH.HASAN

00903 14/01/2016 Clorilex 100 100 mg

23 147.200,00

147.200

269

0000166732053 P SALAMA

00911 14/01/2016 Glimepiride 4 mg

23

12.659,20

12.659

270

0000116987769 P TUNDJIYAH

00919 14/01/2016 Lansoprazole 30 mg

12

7.265,28

198.625

23 191.360,00

69

5.740,80

23

33.414,40

69

9.936,00

Gemfibrozil 300 mg

23

8.508,16

Glimepiride 3 mg

23

11.893,76

00922 14/01/2016 Metformin 500 mg

69

9.936,00

Allopurinol 300 mg

23

5.873,28

Glimepiride 4 mg

23

12.659,20

Gemfibrozil 300 mg

23

8.508,16

23

12.659,20

Micardis 80 mg
271

0001896921167 P ZUBAIDAH

00920 14/01/2016 Propranolol 10 mg


Thyrozol 10 mg

272

273

274

0000117508184 P SUHARSO

0000117508195 I SAHAMI

0001962734624 P ZAINAL ARIFIN

Halaman :

20

00921 14/01/2016 Metformin 500 mg

00923 14/01/2016 Glimepiride 4 mg

39.155

30.338

36.977

31.103

No.

275

276

277

278

No Ka Peserta

Nama

0000775014581 P MARROH

0001818318879 P SYAFRA'IE MW.

0000116950241 P MOH.DAHURI

0000203414905 I SITI HOSNIYAH

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Metformin 500 mg

69

9.936,00

Gemfibrozil 300 mg

23

8.508,16

00924 14/01/2016 Concor 2,5 mg

23

21.962,24

Miniaspi 80 mg

23

4.357,12

Furosemide 40 mg

12

1.305,60

00935 14/01/2016 Furosemide 40 mg

12

1.305,60

Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

23

5.505,28

Spironolacton 25 mg

23

9.273,60

Digoksin 0,25 mg

23

2.855,68

Furosemide 40 mg

23

2.502,40

23

12.835,84

Ramipril 5 mg

23

17.075,20

Gemfibrozil 300 mg

23

8.508,16

00937 14/01/2016 Amlodipine 5 mg

00938 14/01/2016 Glimepiride 2 mg

Harga
Diajukan

27.625

24.652

20.137

38.419

279

0001103653236 P GAZI

00943 14/01/2016 Micardis 40 mg

23 114.816,00

114.816

280

0000116833915 P MOH. HAKI

00952 15/01/2016 Miniaspi 80 mg

23

4.357,12

7.596

23

3.238,40

Vitamin B6 10 mg
281

0000116821405 I SUDARSIH

00953 15/01/2016 Seretide Diskus 250 250 mcg/puff

282

0001383285857 P RUMSIATI

00970 15/01/2016 Glicab 80 mg

Metformin 500 mg
283

0001853560517 P SRININGSIH

00975 15/01/2016 Digoksin 0,25 mg


Furosemide 40 mg

1 142.799,58

142.800

46

13.895,68

23.832

69

9.936,00

23

2.855,68

23

2.502,40

284

0000173012872 P DWI PUJI PERTIWI

00977 15/01/2016 Seretide Diskus 250 250 mcg/puff

285

0000116790693 2 DEWI NOERFADYLAH

00978 15/01/2016 Carbamazepine 200 mg

Fenobarbital 30 mg

Halaman :

21

5.358

1 142.799,58

142.800

46

14.425,60

39.308

R.01

69

8.655,36

Tiamin HCl (Vitamin B1) 50 mg

R.01

25

960,00

Vitamin B6 10 mg

R.01

25

3.520,00

Phenytoin 100 mg

R.01

69

11.746,56

No.

No Ka Peserta

286

0000775174926 P HALILI

287

Nama

0000117584177 P ABD SHAMAD, S.PD

No
Rsp

Tgl Pel

Nama Obat

00979 15/01/2016 Spironolacton 25 mg

Jml
R/N Obt

Harga
Obat

23

9.273,60

Furosemide 40 mg

23

2.502,40

Micardis 40 mg

23 114.816,00

1 107.534,70

1 107.100,00

00980 15/01/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

Harga
Diajukan
126.592

214.635

288

0001048355021 P ARYANI

00981 15/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

289

0000116790682 I KUSUMA WARNI


NINGSIH
0000169859002 I NANIK LISTIAWATI

00987 15/01/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

00988 15/01/2016 Akarbose 50 mg

46

45.926,40

74.027

Amlodipine 5 mg

23

5.505,28

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

00989 15/01/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

Micardis 40 mg

23 114.816,00

23

11.893,76

69

9.936,00

46

14.425,60

Diazepam 2 mg

23

1.324,80

Phenytoin 100 mg

69

11.746,56

23

27.968,00

27.968

R.01 31,0
5
R.02 1,38

5.285,95

5.719

290

291

292

0000116978411 P LIMANI

0001279756697 P SARIYAH

00994 15/01/2016 Glimepiride 3 mg


Metformin 500 mg

293

0000775174612 P ABD RAHMAN

01004 16/01/2016 Carbamazepine 200 mg

294

0000098119484 P SUDARTO

01013 16/01/2016 Glikuidon 30 mg

295

0000776168515 P MOH.HEKAM

01015 16/01/2016 Phenytoin 100 mg


Carbamazepine 200 mg

296

0000203899465 I DJUHARIJATI

01018 16/01/2016 Furosemide 40 mg

297

298

0000116983719 P KUTSIYAH

23

23 114.816,00

4 430.138,80

Micardis 40 mg

23 114.816,00

Lantus Solostar 100 UI/ml

1 107.100,00

0000777064667 P FADILAH

Halaman :

22

01020 16/01/2016 Novorapid Flexpen 100 UI/ml

01026 16/01/2016 Furosemide 40 mg

46

21.830

27.497

432,77

Micardis 40 mg

146.361

2.502,40

5.004,80

117.318

652.055

9.951

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Captopril 25 mg

Jml
R/N Obt

Harga
Obat

46

4.945,92

Harga
Diajukan

299

0000775047914 P SUJAI

01028 16/01/2016 Spironolacton 25 mg

23

9.273,60

9.274

300

0000209712251 P SURATININGSIH

01029 16/01/2016 Glicab 80 mg

23

6.947,84

417.343

Amlodipine 10 mg

23

9.715,20

Novomix Flexpen 100 UI/ml

301

302

0000776138859 P HALIFAH

0000049200186 P BAIDAI

01030 16/01/2016 Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

Micardis 40 mg

23 114.816,00

23

23 114.816,00

01034 16/01/2016 Amlodipine 5 mg

23

5.505,28

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

23

6.947,84

69

9.936,00

23

4.357,12

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

01033 16/01/2016 Amlodipine 5 mg


Diovan 80 mg

303

304

0000116983394 S ACH. SYAFI'IE

0000116926255 I MUSLIMAH

01035 16/01/2016 Glicab 80 mg


Metformin 500 mg

305

0000116926244 P ABD. SAMAD, A.MA

3 400.680,00

01037 16/01/2016 Miniaspi 80 mg

5.505,28

127.034

120.321

27.335

16.884

21.403

306

0000117040645 P PADDUS

01038 16/01/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

307

0000166411901 I ROFIQAH

01039 16/01/2016 Thyrozol 10 mg

23

33.414,40

39.155

69

5.740,80

Propranolol 10 mg
308

0001827152199 P NURUL KARIMAH

01044 16/01/2016 Lantus Solostar 100 UI/ml

309

0000116848844 P MIFTAHOL ARIFIN, SH,


MM

01046 16/01/2016 Amlodipine 5 mg

310

311

0000774580397 P MAHSUNAH

0000774578654 P NUR FADILAH

23

107.100

5.505,28

327.675

23

Novorapid Flexpen 100 UI/ml

2 215.069,40

Lantus Solostar 100 UI/ml

1 107.100,00

01047 16/01/2016 Thyrozol 10 mg

46

66.828,80

Propranolol 10 mg

69

5.740,80

01049 16/01/2016 Alprazolam 0,5 mg

23

6.300,16

46 379.776,00

Olandoz 5 5 mg

Halaman :

1 107.100,00

72.570

386.076

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

312

0001106407596 P SISILIA KLIANI

01050 16/01/2016 Risperidon 3 mg

46 117.760,00

117.760

313

0000202742728 1 ALIFAH RIZKA PUTRI

01052 16/01/2016 Trifluoperazin 5 mg

46

23.846,40

98.680

58

74.833,92

Nama

Tgl Pel

Nama Obat

Risperidon 2 mg
314

0000098228834 P ABD. KAMAR

01054 16/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

315

0000774393614 P GUNAWAN AGUS


SUSANTO

01055 16/01/2016 Clorilex 100 100 mg

12

76.800,00

142.451

Alprazolam 0,5 mg

23

6.300,16

Risperidon 2 mg

46

59.351,04

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Concor 2,5 mg

23

21.962,24

23

13.925,12

Propiltiourasil 100 mg

69

28.174,08

Propranolol 10 mg

69

5.740,80

46

66.828,80

46

3.827,20

23

4.357,12

Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

23

17.075,20

23

7.212,80

69

11.746,56

23

9.273,60

Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

23

17.075,20

316

317

318

0000049204271 P HATIMAH

0000775485966 P ARTINI

0000775898155 P MISPARI

01060 18/01/2016 Miniaspi 80 mg

01062 18/01/2016 Lansoprazole 30 mg

01063 18/01/2016 Thyrozol 10 mg


Propranolol 10 mg

319

320

0000776116258 P SUTIYEH

0000777784127 P SUBAIRI

01064 18/01/2016 Miniaspi 80 mg

01065 18/01/2016 Carbamazepine 200 mg


Phenytoin 100 mg

321

322

0000775878186 P MOH RIFAI

0000116973213 P MOH. SUKRI

01068 18/01/2016 Spironolacton 25 mg

01069 18/01/2016 Lantus Solostar 100 UI/ml


Novomix Flexpen 100 UI/ml

1 107.100,00

4 534.240,00

34.092

47.840

70.656

23.935

18.959

28.851

641.340

323

0000117027584 P ABD HALIK

01070 18/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

324

0001128802419 P MOCH.SAHID

01075 18/01/2016 Spironolacton 25 mg

23

9.273,60

28.851

Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

23

17.075,20

Halaman :

24

No.

No Ka Peserta

325

0000116847832 P MOHAMMAD BADRUL

326

327

328

Nama

0000117081876 P MARIA THERESIA


SETYAWATI

0001388730036 P ABD.HAMID

0001960351187 P RUSLAN MULYADI

No
Rsp

Tgl Pel

Nama Obat

01076 18/01/2016 Glimepiride 4 mg

0000000186906 2 SANIA ZAMHARIRA

Harga
Obat

23

12.659,20

Metformin 500 mg

69

9.936,00

01077 18/01/2016 Simvastatin 10 mg

23

4.975,36

Clopidogrel 75 mg

23 100.096,00

01078 18/01/2016 Akarbose 100 mg

46

58.291,20

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

23

11.893,76

23

17.075,20

46

66.828,80

46

3.827,20

01079 18/01/2016 Glimepiride 3 mg


Ramipril 5 mg

329

Jml
R/N Obt

01085 18/01/2016 Thyrozol 10 mg


Propranolol 10 mg

Harga
Diajukan
22.595

105.071

80.886

28.969

70.656

330

0000169910627 S RUKSIN

01086 18/01/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

331

0000776623059 P JUMAATI

01087 18/01/2016 Thyrozol 10 mg

23

33.414,40

39.155

Propranolol 10 mg

69

5.740,80

01088 18/01/2016 Amlodipine 10 mg

23

9.715,20

Irbesartan 300 mg

23

72.716,80

Dopamet 250 mg

69

70.656,00

01089 18/01/2016 Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

Dopamet 250 mg

69

70.656,00

Irbesartan 150 mg

23

41.952,00

23

6.859,52

12

2.211,84

332

333

334

0001321097319 P ABDUL HOLID

0001260878646 P H.MAWARDI

0001080567527 P ABDURACHMAN

01090 18/01/2016 Alprazolam 1 mg


Klorpromazin 100 mg

153.088

124.826

9.071

335

0001266413264 P KOMARIYATUN

01091 18/01/2016 Propranolol 10 mg

46

3.827,20

3.827

336

0000776047612 P RIZA UMAMI

01112 18/01/2016 Carbamazepine 200 mg

46

14.425,60

26.172

69

11.746,56

Phenytoin 100 mg
337

0000116986509 P SITTI ROKAYYAH NASIR 01114 18/01/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

338

0001048860876 P DAHRIYA

01131 18/01/2016 Miniaspi 80 mg

23

4.357,12

195.717

Micardis 80 mg

23 191.360,00

Halaman :

25

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

339

0000116987062 P SUKRAH

01132 18/01/2016 Glibenklamide 5 mg

23

1.648,64

1.649

340

0000116909954 I RR. SOELAMI WS.

01133 18/01/2016 Glicab 80 mg

23

6.947,84

105.426

Berotec MDI 100 mcg/puff

91.854,00

Metformin 500 mg

46

6.624,00

23

4.357,12

23

7.801,60

23

31.648,00

Allopurinol 100 mg

23

2.531,84

01144 18/01/2016 Trifluoperazin 5 mg

46

23.846,40

Clorilex 100 100 mg

12

76.800,00

23

6.947,84

69

9.936,00

46

66.828,80

69

5.740,80

01150 18/01/2016 Ramipril 5 mg

23

17.075,20

17.075

01156 18/01/2016 Glimepiride 3 mg

23

11.893,76

53.492

Captopril 25 mg

69

7.418,88

Fenofibrate 100 mg

23

31.648,00

Allopurinol 100 mg

23

2.531,84

23

4.357,12

Lisinopril 10 mg

23

17.664,00

Lansoprazole 30 mg

23

13.925,12

341

Nama

0000116841734 I WAKIAH

Tgl Pel

Nama Obat

01134 18/01/2016 Miniaspi 80 mg


Glimepiride 1 mg

342

343

344

0000774764763 P SULASTRI

0001410416177 P FATHOR RAHMAN

0000116932509 P DJUHAIRIJAH

01136 18/01/2016 Fenofibrate 100 mg

01145 18/01/2016 Glicab 80 mg


Metformin 500 mg

345

0001048374922 P SAMI

01146 18/01/2016 Thyrozol 10 mg


Propranolol 10 mg

346
347

348

0000116628974 P ZAINIYAH JD. M. ALI


MAS'UD
0000173585316 P SUPRIYADI

0000116668023 P AHMAD KHOIRI

01164 19/01/2016 Miniaspi 80 mg

349

0000117462813 P MISNOTO

01173 19/01/2016 Seretide Diskus 250 250 mcg/puff

350

0000116939542 P HJ.SITI JASIRAH

01180 19/01/2016 Glicab 80 mg

Amlodipine 10 mg

351

0000117033614 P SITI RAMLAH

26

34.180

100.646

16.884

72.570

35.946

1 142.799,58

142.800

46

13.895,68

36.049

23

9.715,20

Furosemide 40 mg

23

2.502,40

Metformin 500 mg

69

9.936,00

46

13.895,68

23

4.357,12

01181 19/01/2016 Glicab 80 mg


Miniaspi 80 mg

Halaman :

12.159

27.968

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Amlodipine 10 mg

352

353

0000116935986 P H. MOH. EKSAN HS

0000116984968 P MUNIRY

Jml
R/N Obt

Harga
Obat

23

9.715,20

46

13.895,68

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

01190 19/01/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Bisoprolol 5 mg

23

18.988,80

01182 19/01/2016 Glicab 80 mg

Harga
Diajukan

27.968

40.598

354

0000198517465 2 MUSYARROFAH

01196 19/01/2016 Haloperidol 0,5 mg

46

3.473,92

3.474

355

0001048544109 P NUR AZIZEH

01197 19/01/2016 Phenytoin 100 mg

69

11.746,56

11.747

356

0001827829157 P DIAH IMMIYATI

01200 19/01/2016 Captopril 25 mg

69

7.418,88

39.067

23

31.648,00

Fenofibrate 100 mg
357

0001805784761 P MOH.NAJIYANTO

01204 19/01/2016 Glimepiride 4 mg

23

12.659,20

12.659

358

0000159399516 P SITI SUPRAPTI

01205 19/01/2016 Amlodipine 5 mg

23

5.505,28

5.505

359

0000116909998 P MAMNU'AH, A.MA

01217 19/01/2016 Diovan 80 mg

23 114.816,00

114.816

360

0000117035559 P MASODAH

01218 19/01/2016 Miniaspi 80 mg

23

4.357,12

203.489

Isosorbid Dinitrat 5 mg

69

7.772,16

Candesartan Cilexetil 8 mg

23

91.264,00

Clopidogrel 75 mg

23 100.096,00

361

0000203414905 I SITI HOSNIYAH

01219 19/01/2016 Glimepiride 3 mg

23

11.893,76

11.894

362

0000774115964 P SUDI

01230 19/01/2016 Thyrozol 5 mg

23

16.574,72

20.402

Propranolol 10 mg

46

3.827,20

01231 19/01/2016 Propranolol 10 mg

69

5.740,80

Propiltiourasil 100 mg

46

18.782,72

01237 19/01/2016 Propiltiourasil 100 mg

138

56.348,16

69

5.740,80

23 191.360,00

23

9.715,20

23

33.414,40

23

1.913,60

363

364

0000775245317 P ROKAYYAH

0000774156688 S SUCIPTO

Propranolol 10 mg
365

0000116798567 I DEWI
ANGGRAYININGSIH, ST

01238 19/01/2016 Micardis 80 mg


Amlodipine 10 mg

366

0001200312955 P RYAN YULITA

01242 19/01/2016 Thyrozol 10 mg


Propranolol 10 mg

Halaman :

27

24.524

62.089

201.075

35.328

No.

No Ka Peserta

367

0000198517342 I IZZATI

Nama

No
Rsp

Tgl Pel

Nama Obat

01247 19/01/2016 Glimepiride 3 mg

369

0000117298451 P TRI WIDOKINASIH JD


MOH. ISKANDAR
0000117011946 P RAHAYU SUSILAWATI

0000774888456 P HALIMA

Harga
Diajukan

23

11.893,76

69

9.936,00

01260 19/01/2016 Amlodipine 5 mg

23

5.505,28

5.505

01261 19/01/2016 Novorapid Flexpen 100 UI/ml

4 430.138,80

537.239

1 107.100,00

Lantus Solostar 100 UI/ml


370

Harga
Obat

Metformin 500 mg
368

Jml
R/N Obt

01262 19/01/2016 Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

Concor 2,5 mg

23

21.962,24

21.830

33.738

371

0000116996894 P TITIK RUKIATI

01268 19/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

372

0001410230518 P MUSLIMAH

01289 20/01/2016 Levopar 125 mg komb

69 132.480,00

132.480

373

0000773943884 P ROHMAN SODIK

01295 20/01/2016 Vitamin B6 25 mg

16

1.228,80

12.975

Phenytoin 100 mg

69

11.746,56

23 191.360,00

23

374

0000116938967 P HJ. HASIRAH

01296 20/01/2016 Micardis 80 mg


Amlodipine 10 mg

375

0001317289937 P HAIRIYAH

01299 20/01/2016 Novorapid Flexpen 100 UI/ml


Captopril 25 mg

376

377

0001410235659 P SYAIFUL ZAIN

0000173770918 2 ANISATUL KAMILAH

379

0000116931789 P DARSONO

0000117130037 P HERI WIDIASTUTI

Halaman :

28

9.715,20

4 430.138,80

69

7.418,88

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Ramipril 5 mg

23

17.075,20

2.041,60

23

3.150,08

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

Allopurinol 100 mg

23

2.531,84

69

7.772,16

Allopurinol 300 mg

23

5.873,28

Miniaspi 80 mg

23

4.357,12

Lisinopril 10 mg

23

17.664,00

01303 20/01/2016 Miniaspi 80 mg

01306 20/01/2016 Propiltiourasil 100 mg


Propranolol 40 mg

378

01311 20/01/2016 Miniaspi 80 mg

01317 20/01/2016 Isosorbid Dinitrat 5 mg

201.075

437.558

29.204

5.192

24.376

45.603

No.

380

381

No Ka Peserta

Nama

0000116556761 I RUSMAH

0000116984687 P MOHAMMAD PANJAR

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Metformin 500 mg

69

9.936,00

01320 20/01/2016 Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Allopurinol 100 mg

990,72

Diovan 80 mg

23 114.816,00

2 215.069,40

01321 20/01/2016 Novorapid Flexpen 100 UI/ml


Allopurinol 300 mg

Lantus Solostar 100 UI/ml

1 107.100,00

23

Harga
Diajukan

144.511

328.043

5.873,28

382

0000117125943 P HARFINI

01323 20/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

383

0000166446213 S MOH. AFFAN

01324 20/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

384

0000778296137 P NURHAYATI

01326 20/01/2016 Captopril 50 mg

69

12.364,80

31.107

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

16

8.806,40

23 191.360,00

Metformin 500 mg

69

Lantus Solostar 100 UI/ml

385

386

387

388

0000117130972 P DIDIK ATRAWI

0000117131117 P MOHAMMAD ANSHARI

0000117131229 P TOHARI

0000774193792 P SALUKI

01327 20/01/2016 Micardis 80 mg

23

8.508,16

Glibenklamide 5 mg

23

1.648,64

Lantus Solostar 100 UI/ml

N
N

23

8.508,16

Metformin 500 mg

69

9.936,00

01330 20/01/2016 Miniaspi 80 mg

23

4.357,12

Micardis 80 mg

23 191.360,00

Furosemide 40 mg

23

01341 20/01/2016 Seretide Diskus 100 100 mcg/puff

390

0000773652958 P MONARI

01344 20/01/2016 Miniaspi 80 mg

Glimepiride 3 mg
Metformin 500 mg

117.257

1 107.100,00

Novomix Flexpen 100 UI/ml

0001082479059 P FERI BUDIANTO

29

1 107.100,00

389

Halaman :

9.936,00

01328 20/01/2016 Gemfibrozil 300 mg

01329 20/01/2016 Gemfibrozil 300 mg

308.396

152.004

1 133.560,00

198.220

2.502,40

1 127.049,58

127.050

23

4.357,12

26.187

23

11.893,76

69

9.936,00

No.

No Ka Peserta

391

0000117025841 P FATHOR ARIFIN

392

Nama

0000116813946 P MOH ABUSALIM

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

01345 20/01/2016 Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

Candesartan Cilexetil 16 mg

23 144.256,00

3 322.604,10

2 214.200,00

01346 20/01/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

Harga
Diajukan
156.474

536.804

393

0000117464668 I HJ.KISNANIYAH

01348 20/01/2016 Ramipril 10 mg

23

29.822,72

29.823

394

0000774820236 P SITTI FATMA

01349 20/01/2016 Propiltiourasil 100 mg

138

56.348,16

62.089

69

5.740,80

Propranolol 10 mg
395

0001410103822 P HAMIDAH

01350 20/01/2016 Glimepiride 3 mg

23

11.893,76

11.894

396

0000778067919 P ANI MUFIDA

01352 20/01/2016 Thyrozol 10 mg

23

33.414,40

35.328

23

1.913,60

Propranolol 10 mg
397

0001048570378 P BADRIYAH

01358 20/01/2016 Captopril 50 mg

69

12.364,80

12.365

398

0000778200535 P MASNIRAH

01359 20/01/2016 Glimepiride 4 mg

23

12.659,20

12.659

399

0000116984092 P MARYAMA

01360 20/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

400

0000776314855 P HELMIYAH SUNAMI

01361 20/01/2016 Glimepiride 4 mg

23

12.659,20

83.600

Metformin 500 mg

69

9.936,00

Propiltiourasil 100 mg

138

56.348,16

Propranolol 40 mg

34

4.656,64

23

4.357,12

69

7.772,16

46

23.846,40

23

4.239,36

23

12.659,20

69

9.936,00

401

0001969251017 P JUMAT

01362 20/01/2016 Miniaspi 80 mg


Isosorbid Dinitrat 5 mg

402

0000775334878 P SUBAIDI

01363 20/01/2016 Trifluoperazin 5 mg


Klorpromazin 100 mg

403

0001268418677 P SUHAIRIYAH

01364 21/01/2016 Glimepiride 4 mg


Metformin 500 mg

404

0000149090984 P RIFADI

01367 21/01/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

4 430.138,80

2 214.200,00

12.129

28.086

22.595

644.339

405

0000117001732 S BITUNG LUGITO

01373 21/01/2016 Alprazolam 0,5 mg

23

6.300,16

6.300

406

0000116896713 P H.SLAMET,A.MD

01374 21/01/2016 Alprazolam 0,5 mg

23

6.300,16

6.300

407

0000116997671 P R HERRY TRIATMOKO

01375 21/01/2016 Trifluoperazin 5 mg

46

23.846,40

23.846

Halaman :

30

No.

No Ka Peserta

408

0001477910441 P MOH.SHUBAIH AFANDI

Nama

No
Rsp

Tgl Pel

Nama Obat

01388 21/01/2016 Allopurinol 300 mg

0000116984103 S SUDARMO

Harga
Obat

Harga
Diajukan

23

5.873,28

23

12.659,20

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

12

8.647,68

8.648

Glimepiride 4 mg
409

Jml
R/N Obt

01391 21/01/2016 Miniaspi 80 mg

18.532

21.844

410

0000117049702 P NORHAYATI

01393 21/01/2016 Thyrozol 5 mg

411

0000117032681 P NANIK SUGIARTI

01396 21/01/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

215.069

412

0000117121522 P LIEN CHAJATI

01397 21/01/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

215.069

413

0001482889037 P SUGIYONO

01398 21/01/2016 Trifluoperazin 5 mg

23

11.923,20

395.939

Olandoz 5 5 mg

46 379.776,00

Klorpromazin 100 mg

23

4.239,36

23

20.608,00

Propranolol 40 mg

35

4.793,60

Furosemide 40 mg

46

5.004,80

23 191.360,00

23

12.659,20

23

39.479,04

Foransi 10 10 mg

23

12.335,36

Alprazolam 0,5 mg

23

6.300,16

23 191.360,00

69

414

415

0001875917564 P MISTALI

0000116996589 P MOCH BADRUT TAMAN,


A.MA

01399 21/01/2016 Kalipar 300 mg

01405 21/01/2016 Micardis 80 mg


Glimepiride 4 mg

416

417

0001871727805 P MISNATI

0000081456838 P SOEHARTI

01406 21/01/2016 Merlopam 2 mg

01409 21/01/2016 Micardis 80 mg


Isosorbid Dinitrat 5 mg

30.406

204.019

58.115

199.132

7.772,16

418

0000774077769 P SLAMA

01417 21/01/2016 Stalevo 325 mg komb

46 524.032,00

524.032

419

0000777308499 P ABD SAKUR

01419 21/01/2016 Carbamazepine 200 mg

23

7.212,80

18.959

69

11.746,56

23 191.360,00

Novorapid Flexpen 100 UI/ml

3 322.604,10

Lantus Solostar 100 UI/ml

1 107.100,00

Phenytoin 100 mg
420

0000116932116 P DJAMALIYAH

01421 21/01/2016 Micardis 80 mg

421

0000116926255 I MUSLIMAH

422

0000166178733 P SITI NURUL KOMARIYAH 01429 21/01/2016 Propiltiourasil 100 mg

Halaman :

31

01428 21/01/2016 Furosemide 40 mg

621.064

12

1.305,60

1.306

69

28.174,08

31.324

No.

423

424

425

426

No Ka Peserta

Nama

0000117099314 2 MASNUN NUR


ARIFANIYAH

0000117516611 I ERNAWATI

0001862854931 P MUHAMAD HAMID

0000117065215 P BUSRI

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Propranolol 40 mg

23

01432 21/01/2016 Olandoz 10 10 mg

23 329.728,00

Alprazolam 0,5 mg

23

6.300,16

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

Captopril 50 mg

69

12.364,80

23

4.357,12

Carbamazepine 200 mg

46

14.425,60

Lisinopril 5 mg

12

5.376,00

23

5.873,28

23

12.835,84

01438 21/01/2016 Miniaspi 80 mg

01440 21/01/2016 Miniaspi 80 mg

01441 21/01/2016 Allopurinol 300 mg


Glimepiride 2 mg

Harga
Diajukan

3.150,08

427

0001270168301 P ACH.KUSWANDI

01644 21/01/2016 Top Up Hemofilia RS B Reg I NULL

428

0001878185068 P SYAMSUL A.

01445 22/01/2016 Captopril 25 mg

1 7.914.200,0
0
46
4.945,92

Glimepiride 2 mg

23

12.835,84

Metformin 500 mg

69

9.936,00

336.028

25.800

24.159

18.709

7.914.200
27.718

0000147913481 P ANDI CHANDRA


01447 22/01/2016 Seretide Diskus 250 250 mcg/puff
KURNIAWAN
0001126067411 P AHMAD JUFRI SETIAWAN 01448 22/01/2016 Novorapid Flexpen 100 UI/ml
HADI
Lantus Solostar 100 UI/ml

1 142.799,58

142.800

2 215.069,40

322.169

1 107.100,00

431

0000116902934 P ACH BUHARI

01454 22/01/2016 Harnal Ocas 0,4 mg

23 200.192,00

200.192

432

0000775460182 P MISTANI

01469 22/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

433

0000049203808 P H.M. ABD. KADIR AMA

01478 22/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

434

0000117055743 P RASIDI, S.PD.I

01479 22/01/2016 Miniaspi 80 mg

23

4.357,12

12.129

Isosorbid Dinitrat 5 mg

69

7.772,16

429
430

435

0000778467431 P ENY BUDIARTI

01481 22/01/2016 Symbicort 160/4.5mcg

436

0000774148397 P BUSIYAH

01486 22/01/2016 Glimepiride 3 mg

Metformin 500 mg

1 148.176,00

148.176

23

11.893,76

21.830

69

9.936,00

437

0000117030036 P SUDIONO

01487 22/01/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

438

0000774762513 P HARI

01488 22/01/2016 Symbicort 80/4.5mcg

1 139.230,00

139.230

Halaman :

32

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

439

0000774324404 P HASUNAH

01489 22/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

440

0000774233166 P ABDUS SYUKUR

01492 22/01/2016 Spironolacton 25 mg

23

9.273,60

11.776

Furosemide 40 mg

23

2.502,40

Nama

Tgl Pel

Nama Obat

441

0001270057544 P SANIYAH

01493 22/01/2016 Furosemide 40 mg

23

2.502,40

2.502

442

0001795238853 P IBNU SARNOTO

01494 22/01/2016 Glimepiride 2 mg

23

12.835,84

270.686

Isosorbid Dinitrat 5 mg

69

7.772,16

Lansoprazole 30 mg

23

13.925,12

Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Metformin 500 mg

69

9.936,00

Clopidogrel 75 mg

23 100.096,00

Simvastatin 20 mg

23

11.511,04

Candesartan Cilexetil 8 mg

23

91.264,00

46

66.828,80

Propranolol 10 mg

23

1.913,60

01506 23/01/2016 Amlodipine 10 mg

23

9.715,20

23

18.988,80

443

444

0000116784268 I TRITARTINAH AZIS

0000773891076 P ARIYAH

01505 23/01/2016 Thyrozol 10 mg

Bisoprolol 5 mg
445

0000773892494 P KAMARIATUL JANNAH

01510 23/01/2016 Seretide Diskus 250 250 mcg/puff

446

0000116985688 P RIANA TJITRA

01512 23/01/2016 Amlodipine 10 mg

23

23 114.816,00

23

11.893,76

69

9.936,00

Micardis 40 mg
447

0000116917176 I MAISINTI

01513 23/01/2016 Glimepiride 3 mg


Metformin 500 mg

68.742

28.704

1 142.799,58

142.800

9.715,20

124.531

21.830

448

0000116995858 I RUSMIYATI

01515 23/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

449

0000165727708 I NOER FADLILLAH

01516 23/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

450

0000116939182 P HJ. SUFIATI

01517 23/01/2016 Glicab 80 mg

23

6.947,84

141.415

Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

Micardis 40 mg

23 114.816,00

23

451

0001305478552 P MURIAMI

Halaman :

33

01519 23/01/2016 Amlodipine 10 mg

9.715,20

19.636

No.

452

453

454

No Ka Peserta

Nama

0001048637463 P FARIDAH

0000116886137 I SITI AISJAH

0000116886126 P MOCH. IKSAN

No
Rsp

Tgl Pel

Nama Obat

0000116963684 P SATUAH JD SURI

23

2.502,40

Captopril 25 mg

69

7.418,88

69

28.174,08

Propranolol 10 mg

69

5.740,80

01522 23/01/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

69

9.936,00

Allopurinol 100 mg

23

2.531,84

23

9.715,20

23 114.816,00

23

23 114.816,00

23

5.505,28

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

01521 23/01/2016 Propiltiourasil 100 mg

01523 23/01/2016 Amlodipine 10 mg

01524 23/01/2016 Amlodipine 10 mg


Micardis 40 mg

456

0000117021227 P MOHAMAD HARIYADI D

Harga
Obat

Furosemide 40 mg

Micardis 40 mg
455

Jml
R/N Obt

01531 23/01/2016 Amlodipine 5 mg

9.715,20

Harga
Diajukan

33.915

42.585

124.531

124.531

20.490

457

0000117432753 P DRA. SRI AGUSTINI

01534 23/01/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

458

0000117126369 1 DWI CANDRA BAGUS K.

01537 23/01/2016 Clorilex 100 100 mg

38.400,00

418.176

Olandoz 5 5 mg
459

460

0000117006254 P ABDUL KADIR JAMALI

0000116923781 P ISHAK

46 379.776,00

23

4.357,12

Ramipril 5 mg

12

8.908,80

Lantus Solostar 100 UI/ml

Metformin 500 mg

69

9.936,00

01543 23/01/2016 Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

01540 23/01/2016 Miniaspi 80 mg

130.302

1 107.100,00

12.218

461

0000117125594 P SITI TITIK FARHATIN

01546 23/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

462

0000172426015 S SAMSUL IMAM

01547 23/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

463

0000977368588 S ABRAHAM AJIE

01548 23/01/2016 Depakote ER 250 mg

46 164.451,84

241.252

12

76.800,00

23

9.715,20

Clorilex 100 100 mg


464

0000116932882 P DR.H.IMAM

Halaman :

34

01552 23/01/2016 Amlodipine 10 mg

9.715

No.
464

No Ka Peserta

Nama

0000116932882 P

465

KUSMADI,DSA
0001106407596 P SISILIA KLIANI

466

0000774216358 P MASRIFAH

No
Rsp

Tgl Pel

Nama Obat

01552 23/01/2016 Amlodipine 10 mg

0001048494688 P ERFAN ARIFANDI

0001326019331 P UMMU SALAMAH

01553 23/01/2016 Olandoz 5 5 mg

46 379.776,00

379.776

01554 23/01/2016 Nopres 20 mg

12

6.635,52

386.412

46 379.776,00

23

46 379.776,00

01556 23/01/2016 Alprazolam 0,5 mg

01557 23/01/2016 Clorilex 100 100 mg


Olandoz 5 5 mg

469

0000775584922 P HOLILATULHOSNA

471

472

0001884740354 P TITIK SUMIATI

0000116945807 P MOCH. SADALI

0000775354072 P RODIYAH

474

475

476

0000776556483 P MUDIAH

0001048512159 P ABD.GAFUR

0001270104693 P KRISTIN SUSILOWATI

0000777765688 P SAHEMAH

35

38.400,00

46

46 379.776,00

01568 25/01/2016 Glimepiride 3 mg

23

11.893,76

Akarbose 100 mg

46

58.291,20

Ramipril 5 mg

23

17.075,20

Metformin 500 mg

69

9.936,00

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

23

17.075,20

Clopidogrel 75 mg

23 100.096,00

01574 25/01/2016 Amlodipine 10 mg

23

9.715,20

23

17.075,20

11

9.081,60

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

01577 25/01/2016 Vitamin B6 10 mg

16

2.252,80

Phenytoin 100 mg

69

11.746,56

23

17.075,20

Amlodipine 10 mg

23

9.715,20

01583 25/01/2016 Amlodipine 10 mg

23

9.715,20

69

7.418,88

01558 23/01/2016 Haloperidol 0,5 mg

01571 25/01/2016 Miniaspi 80 mg

01576 25/01/2016 Bisoprolol 5 mg

01579 25/01/2016 Ramipril 5 mg

Captopril 25 mg

Halaman :

6.300,16

23 189.888,00

Ramipril 5 mg
473

9.715,20

Olandoz 5 5 mg
470

Harga
Diajukan

23

Olandoz 5 5 mg
468

Harga
Obat

Olandoz 5 5 mg
467

Jml
R/N Obt

3.473,92

9.715

386.076

228.288

383.250

97.196

131.803

26.790

20.858

13.999

26.790

17.134

No.

No Ka Peserta

477

0000770052148 P ROTIBAH

478

Nama

0000117022206 I SUYATI

No
Rsp

Tgl Pel

Nama Obat

01586 25/01/2016 Thyrozol 10 mg

Jml
R/N Obt
N

46

66.828,80

Propranolol 10 mg

23

1.913,60

01588 25/01/2016 Amlodipine 10 mg

23

9.715,20

Seretide Diskus 250 250 mcg/puff

Amitriptyline 25 mg

479

0001896757402 P MARYAMAH

01590 25/01/2016 Seretide Diskus 100 100 mcg/puff

480

0000775204042 P NULRUL IMAM

01592 25/01/2016 Spironolacton 25 mg

Isosorbid Dinitrat 5 mg
Furosemide 40 mg
481

0001432117348 P SALANI

01620 25/01/2016 Diovan 80 mg


Glikuidon 30 mg

1 142.799,58
23

3.297,28

9.273,60

18.243

69

7.772,16

11

1.196,80

23 114.816,00

23

483

0000117016165 P LILIK SULAIHA

01628 25/01/2016 Thyrozol 10 mg

Propranolol 10 mg

0001439116694 P SUHARINI

155.812

23

01623 25/01/2016 Seretide Diskus 250 250 mcg/puff

485

68.742

127.050

0001104077812 P AGUS SANTOSO

0000116955911 P NY.R.DJUMAINNA

Harga
Diajukan

1 127.049,58

482

484

Harga
Obat

142.784

27.968,00

1 142.799,58

142.800

23

33.414,40

39.155

69

5.740,80

01649 26/01/2016 Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

Captopril 25 mg

46

4.945,92

69

7.507,20

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

01656 26/01/2016 Furosemide 40 mg

486

0001473917679 P FATAH HIDAYAT

01658 26/01/2016 Novorapid Flexpen 100 UI/ml

487

0000774438399 P SAHERI

01670 26/01/2016 Thyrozol 10 mg

Propranolol 10 mg

17.164

208.582

9.715,20

2 215.069,40

215.069

23

33.414,40

39.155

69

5.740,80

488

0000116940699 I SUJANI

01671 26/01/2016 Glimepiride 3 mg

23

11.893,76

11.894

489

0001372475305 P HARI GUNAWAN

01672 26/01/2016 Glikuidon 30 mg

23

27.968,00

145.286

Furosemide 40 mg

23

2.502,40

Micardis 40 mg

23 114.816,00

01673 26/01/2016 Bisoprolol 5 mg

23

18.988,80

11

1.196,80

490

0000776982339 P SUMA'AH

Furosemide 40 mg

Halaman :

36

20.186

No.

No Ka Peserta

491

0000116961748 P SAGUNG

492
493

Nama

0001291903301 P AGUSTINA SAID


WACHDIN
0000116821405 I SUDARSIH

No
Rsp

Tgl Pel

Nama Obat

01674 26/01/2016 Micardis 80 mg

0000774344272 P JASULI

Harga
Obat

Harga
Diajukan

23 191.360,00

Amlodipine 10 mg

23

9.715,20

01681 26/01/2016 Furosemide 40 mg

23

2.502,40

2.502

01692 26/01/2016 Thyrozol 10 mg

23

33.414,40

39.155

69

5.740,80

23

4.357,12

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Propranolol 10 mg
494

Jml
R/N Obt

01695 26/01/2016 Miniaspi 80 mg

201.075

23.905

495

0000774156453 P MUHIR

01696 26/01/2016 Euthyrox 0,1 mg

23

25.024,00

25.024

496

0001436930831 P MAIMUNAH

01697 26/01/2016 Spironolacton 25 mg

23

9.273,60

11.776

23

2.502,40

Furosemide 40 mg
497

0001895639973 P SUBAGIO

01709 26/01/2016 Miniaspi 80 mg

23

4.357,12

4.357

498

0001048610316 P SAMAH

01711 26/01/2016 Glimepiride 4 mg

23

12.659,20

12.659

499

0000773726894 P SYAMSIYAH

01712 26/01/2016 Amlodipine 10 mg

23

9.715,20

32.310

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

69 132.480,00

16 147.456,00

69 132.480,00

16 147.456,00

23

Micardis 40 mg

23 114.816,00

01754 27/01/2016 Bisoprolol 5 mg

23

18.988,80

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

01757 27/01/2016 Bisoprolol 5 mg

23

18.988,80

Captopril 50 mg

69

12.364,80

23

4.357,12

500

0000117094509 P SAUDATUL MAFRUHAH

01716 26/01/2016 Levopar 125 mg komb


Sifrol ER 375 mcg

501

0000116965484 P SJAMSUDIN, BA

01717 26/01/2016 Levopar 125 mg komb


Sifrol ER 375 mcg

502

503

504

505

0000779286407 P SAPRAWI

0000116937595 P HALIMATUS SA'DIYAH

0000116963357 I SIRA

0000776958581 P SAMAWI

Halaman :

37

01721 26/01/2016 Furosemide 40 mg

01758 27/01/2016 Miniaspi 80 mg

2.502,40

279.936

279.936

117.318

30.765

31.354

11.536

No.

506

507

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

509

510

511

512

Harga
Obat

Harga
Diajukan

Furosemide 40 mg

12

1.305,60

Allopurinol 300 mg

23

5.873,28

46

66.828,80

Propranolol 10 mg

46

3.827,20

01760 27/01/2016 Amlodipine 10 mg

23

9.715,20

23 114.816,00

0001280212547 P MOHAMMAD ZAIFULLAH 01768 27/01/2016 Amlodipine 10 mg


ZIN
Levopar 125 mg komb

23

9.715,20

46

88.320,00

0000778218985 P ROIS

01769 27/01/2016 Vitamin B6 25 mg

23

1.766,40

Phenytoin 100 mg

69

11.746,56

01770 27/01/2016 Miniaspi 80 mg

23

4.357,12

Concor 2,5 mg

23

21.962,24

Allopurinol 300 mg

23

5.873,28

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

01771 27/01/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

9.273,60

12

8.908,80

23

33.414,40

33.414

3 322.604,10

322.604

0000117090044 I ERMA MEGAWATI

0000109714476 P INA SUPARSI

01759 27/01/2016 Thyrozol 10 mg

Diovan 80 mg
508

Jml
R/N Obt

0000117049623 P SOEWONDO

0000116856898 1 SANTA OKTA


PRIANDANA

0001261637728 P JUSUF

01776 27/01/2016 Spironolacton 25 mg


Ramipril 5 mg

70.656

124.531

98.035

13.513

41.270

14.985

18.182

513

0001048624018 P ZAINULLAH

01777 27/01/2016 Thyrozol 10 mg

514

0000116990943 P SUBROTO

01782 27/01/2016 Novorapid Flexpen 100 UI/ml

515

0000116746075 P NURUL KOMAR, S.PD

01783 27/01/2016 Metformin 500 mg

23

3.312,00

3.312

516

0000117177906 P AWIYANI

01786 27/01/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

517

0000774128632 P KIYEH

01787 27/01/2016 Thyrozol 10 mg

23

33.414,40

33.414

518

0000117090797 P JUMRAWI

01788 27/01/2016 Captopril 25 mg

69

7.418,88

7.419

519

0001427006171 P SITI HAIRIYAH

01789 27/01/2016 Spironolacton 100 mg

23

26.496,00

31.153

34

4.656,64

Propranolol 40 mg
520

0000774968602 P CICI ROSIDATUL


JANNAH

01793 27/01/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

Halaman :

38

2 215.069,40

2 214.200,00

429.269

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

521

0000116981864 P DJATIM

01796 27/01/2016 Micardis 80 mg

23 191.360,00

191.360

522

0000117041534 P HAIRUS SHALEH,


A.MA.PD

01805 27/01/2016 Novorapid Flexpen 100 UI/ml

3 322.604,10

429.704

1 107.100,00

Nama

Tgl Pel

Nama Obat

Lantus Solostar 100 UI/ml


523

524

525

526

0000116870951 P M NASIRUDDIN

0000117024726 P SUHARTININGSIH

0000117371081 P SUKANDAR

0001793993016 P SA'DAH

01806 27/01/2016 Glibenklamide 5 mg

46

3.297,28

Metformin 500 mg

46

6.624,00

01807 27/01/2016 Amlodipine 10 mg

23

9.715,20

Concor 2,5 mg

23

21.962,24

01808 27/01/2016 Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Diovan 80 mg

23 114.816,00

Metformin 500 mg

46

6.624,00

4.238,08

01813 27/01/2016 Lansoprazole 30 mg


Diovan 80 mg

23 114.816,00

9.921

31.677

135.512

119.054

527

0001966126836 P SUTINA

01815 27/01/2016 Micardis 40 mg

23 114.816,00

114.816

528

0001717473104 P NASIDEH

01820 28/01/2016 Furosemide 40 mg

23

2.502,40

193.862

23 191.360,00

23

9.715,20

Levopar 125 mg komb

46

88.320,00

Bisoprolol 5 mg

23

18.988,80

Micardis 80 mg
529

0001048464347 P JUANI

01825 28/01/2016 Amlodipine 10 mg

117.024

530

0000770203629 P ABDUS SAKUR

01830 28/01/2016 Olandoz 5 5 mg

46 379.776,00

379.776

531

0000117029474 P AKH BUSIRI

01833 28/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

532

0000116575209 I R. AY. SUFIATI

01836 28/01/2016 Symbicort 160/4.5mcg

1 148.176,00

148.176

533

0000116981188 P AMANIYAH

01838 28/01/2016 Amlodipine 10 mg

23

9.715,20

31.545

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

01839 28/01/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

534

535

0000116827852 P MOH ZAINI

0000117042298 P SRI HARTATI NY

Halaman :

39

01841 28/01/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

31.545

322.169

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Lantus Solostar 100 UI/ml

536

537

538

0000116795799 P ABD RAHMAN

0000116798905 P HENDRO SANTOSO

0000116910797 P MENA JD.II


SANGNGARAN

01847 28/01/2016 Diltiazem 30 mg

Jml
R/N Obt
N

Harga
Obat

1 107.100,00

23

3.944,96

Miniaspi 80 mg

23

4.357,12

Ramipril 5 mg

23

17.075,20

Clopidogrel 75 mg

23 100.096,00

Atenolol 50 mg

23

10.362,88

01849 28/01/2016 Miniaspi 80 mg

23

4.357,12

Amlodipine 5 mg

23

5.505,28

Concor 2,5 mg

23

21.962,24

Candesartan Cilexetil 8 mg

23

91.264,00

23

11.893,76

Allopurinol 300 mg

23

5.873,28

Metformin 500 mg

69

9.936,00

01856 28/01/2016 Glimepiride 3 mg

539

0000163351405 I SUKARTINI

01857 28/01/2016 Seretide Diskus 250 250 mcg/puff

540

0000117142751 P MOCHAMAD RUSLI

01858 28/01/2016 Gemfibrozil 300 mg

Metformin 500 mg
Glimepiride 4 mg

Harga
Diajukan

135.836

123.089

27.703

1 142.799,58

142.800

23

8.508,16

31.103

69

9.936,00

23

12.659,20

541

0001048493327 A WARDATUL LAILIYAH

01859 28/01/2016 Thyrozol 10 mg

23

33.414,40

33.414

542

0001961140768 P SULAIHA

01863 28/01/2016 Propranolol 40 mg

35

4.793,60

32.968

69

28.174,08

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Lansoprazole 30 mg

23

13.925,12

Furosemide 40 mg

12

1.305,60

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Lansoprazole 30 mg

4.238,08

23

16.574,72

23

3.150,08

Propiltiourasil 100 mg
543

544

545

0000776682628 P MARSINI

0001882533464 P NUR MUHAMMAD LATIF

0001302820929 P QURROTUL AINI

01865 28/01/2016 Miniaspi 80 mg

01866 28/01/2016 Miniaspi 80 mg

01871 28/01/2016 Thyrozol 5 mg


Propranolol 40 mg

Halaman :

40

27.360

16.367

19.725

No.

No Ka Peserta

546

0000774977242 P JUHAIRIYAH

Nama

No
Rsp

Tgl Pel

Nama Obat

01872 28/01/2016 Lansoprazole 30 mg

548

549

550

0000775310365 P LUBABAH

0000773886341 P NABILAH MAULANA


ARIFIN

0000775080808 P WASILAH

0001081755786 P TUSRIYAH

Harga
Obat

4.238,08

23

16.574,72

01876 28/01/2016 Allopurinol 300 mg

23

5.873,28

Metformin 500 mg

46

6.624,00

Glimepiride 4 mg

23

12.659,20

Captopril 50 mg

69

12.364,80

23 329.728,00

Alprazolam 1 mg

12

3.578,88

Amitriptyline 25 mg

23

3.297,28

23

3.150,08

Thyrozol 5 mg

23

16.574,72

01884 28/01/2016 Ramipril 5 mg

12

8.908,80

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Thyrozol 5 mg
547

Jml
R/N Obt

01880 28/01/2016 Olandoz 10 10 mg

01883 28/01/2016 Propranolol 40 mg

551

0001048814482 P SUNARIS

01885 28/01/2016 Seretide Diskus 250 250 mcg/puff

552

0001292062871 P UMMI KULSUM

01897 29/01/2016 Miniaspi 80 mg

23

Micardis 80 mg

23 191.360,00

Novorapid Flexpen 100 UI/ml

6 645.208,20

Furosemide 40 mg

23

2.502,40

Fenofibrate 100 mg

23

31.648,00

Lantus Solostar 100 UI/ml

2 214.200,00

Harga
Diajukan
20.813

37.521

336.604

19.725

37.613

1 142.799,58

142.800

4.357,12

1.089.276

553

0001434124787 P TINIYATUN

01902 29/01/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

554

0000116814712 P MUNAKIB

01905 29/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

165.571

Glimepiride 2 mg

23

12.835,84

Metformin 500 mg

69

9.936,00

555

0001302030674 P SUMI TRISNAWATI

01927 29/01/2016 Thyrozol 10 mg

23

33.414,40

33.414

556

0000774635387 P MOH ZAINAL AMIN

01928 29/01/2016 Vitamin B6 10 mg

23

3.238,40

14.985

Phenytoin 100 mg

69

11.746,56

01929 29/01/2016 Vitamin B6 10 mg

23

3.238,40

557

0001048465304 P MOH ZUHDI

Halaman :

41

14.985

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Phenytoin 100 mg

Jml
R/N Obt
N

558

0001138508818 P CAHYO BUDIONO

01930 29/01/2016 Seretide Diskus 250 250 mcg/puff

559

0000775253957 P ABD.ROSID

01933 29/01/2016 Miniaspi 80 mg

Isosorbid Dinitrat 5 mg
Furosemide 40 mg

69

Harga
Obat

Harga
Diajukan

11.746,56

1 142.799,58

142.800

23

4.357,12

13.435

69

7.772,16

12

1.305,60

560

0000116814554 P MOHAMMAD SAHID

01934 29/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

561

0000117008436 P RISKIYAH

01935 29/01/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

562

0000117087085 P PURWANTO

01936 29/01/2016 Levopar 125 mg komb

69 132.480,00

132.480

563

0000117130983 P HAIRUL SALEH

01942 29/01/2016 Metformin 500 mg

69

9.936,00

187.986

Glimepiride 4 mg

23

12.659,20

Lantus Solostar 100 UI/ml

Akarbose 100 mg

46

58.291,20

01943 29/01/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 2 mg

23

12.835,84

Diovan 80 mg

23 114.816,00

Metformin 500 mg

69

9.936,00

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Diovan 80 mg

23 114.816,00

69

9.936,00

Akarbose 100 mg

46

58.291,20

Glimepiride 4 mg

23

12.659,20

46

5.004,80

Concor 2,5 mg

23

21.962,24

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

9.715,20

Kalipar 300 mg

23

20.608,00

564

565

566

567

0000117023253 P SUDARJATI S

0000116830552 P DRS. SANUM MA'MUN,


M.PD.I

0000210456898 S SYAIFUL UMRON

0001268393242 P FATHORRAHMAN

01952 29/01/2016 Miniaspi 80 mg

01956 29/01/2016 Metformin 500 mg

01959 30/01/2016 Furosemide 40 mg

1 107.100,00

147.303

128.888

80.886

248.650

568

0000116980863 P AFANDI

01960 30/01/2016 Captopril 25 mg

23

2.472,96

2.473

569

0001048661291 P WAHYUDI APRIZAL

01961 30/01/2016 Phenytoin 100 mg

69

11.746,56

11.747

Halaman :

42

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

570

0000776109159 P HAKIMAH

01963 30/01/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

571

0000173012725 I MARFU'AH

01964 30/01/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

572

0000116786935 P IMAM SOPHI

01966 30/01/2016 Foransi 10 10 mg

23

12.335,36

207.169

Olandoz 5 5 mg

23 189.888,00

Captopril 25 mg

46

4.945,92

11

70.400,00

Merlopam 2 mg

23

39.479,04

Olandoz 5 5 mg

46 379.776,00

23

16.574,72

23

1.913,60

573

574

Nama

0000166164917 P ANDYKA BUDIHARTO

0000116945032 P MISRIANI

Tgl Pel

Nama Obat

01968 30/01/2016 Clorilex 100 100 mg

01980 30/01/2016 Thyrozol 5 mg


Propranolol 10 mg

489.655

18.488

575

0000116986961 P SUHAMIYATI

01981 30/01/2016 Diovan 80 mg

23 114.816,00

114.816

576

0000200416059 I HANAFIAH

01984 30/01/2016 Glicab 80 mg

23

6.947,84

134.011

Amlodipine 10 mg

23

9.715,20

Allopurinol 100 mg

23

2.531,84

Micardis 40 mg

23 114.816,00

01987 30/01/2016 Miniaspi 80 mg

23

4.357,12

Amlodipine 5 mg

23

5.505,28

Furosemide 40 mg

23

2.502,40

01988 30/01/2016 Amlodipine 10 mg

23

9.715,20

577

578

579

580

581

0000774799222 P SANITO

0001854083586 P BUSANI

0000116959217 I MISRIATUN

0000777977605 P RIFAIE

0001893272815 P ROMLI

Halaman :

43

Novorapid Flexpen 100 UI/ml

2 215.069,40

Lantus Solostar 100 UI/ml

1 107.100,00

01989 30/01/2016 Thyrozol 5 mg

46

Micardis 40 mg

23 114.816,00

Propranolol 10 mg

46

3.827,20

23

33.414,40

Propranolol 10 mg

69

5.740,80

01994 30/01/2016 Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

12

8.908,80

01992 30/01/2016 Thyrozol 10 mg

33.149,44

12.365

331.885

151.793

39.155

21.126

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

582

0001429719377 P SRI WAHYUNINGSIH

01995 30/01/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

583

0001270057544 P SANIYAH

02002 30/01/2016 Candesartan Cilexetil 8 mg

23

91.264,00

91.264

584

0001048489514 P ACH.JUNAIDI

02003 30/01/2016 Spironolacton 25 mg

23

9.273,60

18.636

Furosemide 40 mg

46

5.004,80

Miniaspi 80 mg

23

4.357,12

Nama

Tgl Pel

Nama Obat

585

0001048365718 P TURAH

02004 30/01/2016 Amlodipine 10 mg

23

9.715,20

9.715

586

0001883702788 P RUMSIYAH

02005 30/01/2016 Amlodipine 10 mg

23

9.715,20

37.613

Bisoprolol 5 mg

23

18.988,80

Ramipril 5 mg

12

8.908,80

23

9.715,20

587

588

589

590

591

0000117080065 P BUSTAMI

0000117008403 I SITTI AISYAH

0000116906376 I SITI FATHAH

0001819659925 P MOH.BAHRI

0001855961673 P INSUL ARIF

02013 30/01/2016 Amlodipine 10 mg


Novorapid Flexpen 100 UI/ml

4 430.138,80

Lantus Solostar 100 UI/ml

3 321.300,00

02014 30/01/2016 Amlodipine 5 mg

23

5.505,28

Akarbose 100 mg

46

58.291,20

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

02015 30/01/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

Akarbose 100 mg

46

58.291,20

32.000,00

02016 30/01/2016 Clorilex 100 100 mg


Olandoz 5 5 mg

46 379.776,00

Depakote 250 mg

23

46 379.776,00

02017 30/01/2016 Olandoz 5 5 mg


Clorilex 100 100 mg

592

593

0000211105282 I HASIJAH

0000117033153 P SUHRA

32.000,00

23

17.664,00

Phenytoin 100 mg

69

11.746,56

02021 30/01/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

Glimepiride 4 mg

Halaman :

44

86.392

89.836

461.235

49.459,20

02020 30/01/2016 Lisinopril 10 mg

761.154

411.776

29.411

22.595

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

594

0000774767687 P HORI

00003 01/02/2016 Micardis 80 mg

23 191.360,00

191.360

595

0000774021352 P JAUHARI

00009 01/02/2016 Miniaspi 80 mg

23

4.357,12

37.595

Lisinopril 10 mg

23

17.664,00

Isosorbid Dinitrat 5 mg

69

7.772,16

Glimepiride 1 mg

23

7.801,60

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Miniaspi 80 mg

23

4.357,12

23

2.502,40

23

91.264,00

23

16.574,72

69

5.740,80

23

9.273,60

Furosemide 40 mg

23

2.502,40

00018 01/02/2016 Amlodipine 10 mg

23

9.715,20

23 144.256,00

11

1.548,80

Amlodipine 5 mg

23

5.505,28

Novorapid Flexpen 100 UI/ml

Glimepiride 2 mg

23

12.835,84

Fenofibrate 100 mg

23

31.648,00

Allopurinol 100 mg

23

2.531,84

23

9.273,60

23

2.502,40

91.854,00

91.854
193.862

596

597

Nama

0001834273956 P ABD.JANNANI

0001085741199 P SITI SUNARTI

Tgl Pel

Nama Obat

00010 01/02/2016 Spironolacton 25 mg

00011 01/02/2016 Furosemide 40 mg


Candesartan Cilexetil 8 mg

598

0001451727753 P FALALAH

00014 01/02/2016 Thyrozol 5 mg


Propranolol 10 mg

599

600

0000116970895 P USMAN

0000117324088 I RIHANA

00016 01/02/2016 Spironolacton 25 mg

Candesartan Cilexetil 16 mg
601

602

0000166444806 I SUSMAWARI NINGSIH

0000774511828 P RISKIYAH

00028 01/02/2016 Nifedipin 10 mg

00029 01/02/2016 Spironolacton 25 mg


Furosemide 40 mg

0001282406084 P SUKARSIH NASUTION

00030 01/02/2016 Berotec MDI 100 mcg/puff

604

0001896947008 P SITI RAMLAH

00034 01/02/2016 Micardis 80 mg

23 191.360,00

23

605

0000196713505 I AGUSTINA LENDEN

Halaman :

45

00067 01/02/2016 Seretide Diskus 250 250 mcg/puff

93.766

22.316

11.776

153.971

269.139

2 215.069,40

603

Furosemide 40 mg

23.905

11.776

2.502,40

1 142.799,58

142.800

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

606

0000198713226 1 IRADATUL ILAHIYAH

00068 01/02/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

607

0000163394548 P NAFSHATUN

00083 01/02/2016 Lisinopril 5 mg

23

10.304,00

254.289

608

609

Nama

0000774309598 P BUNIAH

0000116806926 P R A SYARIFAH

Tgl Pel

Nama Obat

Seretide Diskus 250 250 mcg/puff

Akarbose 50 mg

46

45.926,40

Glicab 80 mg

46

13.895,68

Amlodipine 10 mg

23

9.715,20

Fenofibrate 100 mg

23

31.648,00

46

66.828,80

Ramipril 5 mg

23

17.075,20

Propranolol 10 mg

46

3.827,20

23 191.360,00

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Furosemide 40 mg

23

2.502,40

00092 02/02/2016 Thyrozol 10 mg

00093 02/02/2016 Micardis 80 mg

1 142.799,58

87.731

222.566

610

0001048518292 P TITIK WAHYUNI

00094 02/02/2016 Glimepiride 2 mg

23

12.835,84

12.836

611

0000203023361 I SANIMAH

00096 02/02/2016 Glimepiride 2 mg

23

12.835,84

23.140

23

10.304,00

69

21.638,40

Klobazam 10 mg

46

52.992,00

Vitamin B6 10 mg

23

3.238,40

00126 02/02/2016 Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Isosorbid Dinitrat 5 mg

69

7.772,16

Clopidogrel 75 mg

23 100.096,00

Lisinopril 5 mg
612

613

0001884528415 P HOLIDA

0001868602522 P MUHDAR ABDULLAH

00108 02/02/2016 Carbamazepine 200 mg

77.869

131.214

614

0000116784066 P ABD. ADHIM

00127 02/02/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

615

0001536462077 P JUMAT

00128 02/02/2016 Spironolacton 25 mg

23

9.273,60

32.541

Furosemide 40 mg

12

1.305,60

Concor 2,5 mg

23

21.962,24

00129 02/02/2016 Seretide Diskus 250 250 mcg/puff

616

0000166874499 P AHMAD SUHARDI

Halaman :

46

1 142.799,58

142.800

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

617

0001048327211 P MARWAH

00130 02/02/2016 Amlodipine 5 mg

23

5.505,28

5.505

618

0000116782942 P SLAMET SUPRIYADI

00132 02/02/2016 Amlodipine 10 mg

23

9.715,20

197.690

Furosemide 40 mg

23

2.502,40

Micardis 40 mg

23 114.816,00

Dopamet 250 mg

69

70.656,00

Nama

Tgl Pel

Nama Obat

619

0000116980389 P ABDUL MUKTI

00137 02/02/2016 Simvastatin 10 mg

23

4.975,36

4.975

620

0000167798261 I ISTRI

00138 02/02/2016 Ramipril 5 mg

12

8.908,80

151.899

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Clopidogrel 75 mg

23 100.096,00

621

0000116988502 I SUTAN TINAH

00150 02/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

622

0001966149707 P FATIMAH

00151 02/02/2016 Lisinopril 10 mg

23

17.664,00

29.440

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

623

0001295573139 P HATIRAH

00157 02/02/2016 Glimepiride 4 mg

23

12.659,20

12.659

624

0000117100923 P SUFIATUN

00167 02/02/2016 Amlodipine 10 mg

23

9.715,20

124.531

23 114.816,00

46

3.827,20

69

28.174,08

Diovan 80 mg
625

0000773872446 P SAYUMI

00168 02/02/2016 Propranolol 10 mg


Propiltiourasil 100 mg

626

0001449219947 P ALFI TAURIKA

00169 02/02/2016 Seretide Diskus 250 250 mcg/puff

627

0000770165875 P SAFI UDDIN

00180 03/02/2016 Vitamin B6 10 mg

Phenytoin 100 mg
628

0001443194379 P TIHANA

00181 03/02/2016 Isosorbid Dinitrat 5 mg


Furosemide 40 mg

629

0000116946145 P MOELJADI

00182 03/02/2016 Micardis 80 mg


Amlodipine 10 mg

Halaman :

47

32.001

1 142.799,58

142.800

23

3.238,40

14.985

69

11.746,56

69

7.772,16

23

2.502,40

23 191.360,00

23

9.715,20

10.275

204.913

No.

630

No Ka Peserta

Nama

0001048545922 P FERI ANGGA RIAWAN

No
Rsp

Tgl Pel

Nama Obat

0000116875631 P MOH.NAJIB

12

1.305,60

Allopurinol 100 mg

23

2.531,84

23

3.238,40

69

21.638,40

00186 03/02/2016 Vitamin B6 10 mg

00206 03/02/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

632

000098253459

P SUATUN

Harga
Obat

Furosemide 40 mg

Carbamazepine 200 mg
631

Jml
R/N Obt

00208 03/02/2016 Glicab 80 mg

2 215.069,40

1 107.100,00

23

6.947,84

Amlodipine 10 mg

23

9.715,20

Allopurinol 300 mg

23

5.873,28

Simvastatin 10 mg

23

4.975,36

Metformin 500 mg

69

9.936,00

Harga
Diajukan

24.877

322.169

37.448

633

0000116811966 I HJ. ASIYAH

00213 03/02/2016 Micardis 80 mg

23 191.360,00

191.360

634

0001048961709 P SUNING YATIK

00214 03/02/2016 Glimepiride 2 mg

23

12.835,84

22.772

69

9.936,00

23 161.920,00

Micardis 80 mg

23 191.360,00

Gemfibrozil 300 mg

23

8.508,16

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Glimepiride 1 mg

23

7.801,60

Captopril 25 mg

69

7.418,88

Clopidogrel 75 mg

23 100.096,00

00220 03/02/2016 Propranolol 40 mg

23

3.150,08

23

16.574,72

23 161.920,00

23 191.360,00

Metformin 500 mg
635

636

637

0000117004465 P MUHAMAD SYAMSURI

0001410151026 P HASUNAH

0000774156453 P MUHIR

00215 03/02/2016 Gliclazide 60 mg

00219 03/02/2016 Isosorbid Dinitrat 5 mg

Thyrozol 5 mg
638

0000204334334 P EMAD

00221 03/02/2016 Gliclazide 60 mg


Micardis 80 mg

361.788

127.446

19.725

353.280

639

0000774604247 P SUNAH

00224 03/02/2016 Glimepiride 3 mg

46

23.787,52

23.788

640

0000117081606 I SITI HAMIDAH

00225 03/02/2016 Miniaspi 80 mg

23

4.357,12

4.357

641

0000775783934 P MAE

00232 03/02/2016 Phenytoin 100 mg

2.701,71

2.702

642

0000116604865 P RACHMATUL LAILI

00233 03/02/2016 Gemfibrozil 300 mg

R.01 15,8
7
23
N

8.508,16

8.508

Halaman :

48

No.
642
643

644

No Ka Peserta

Nama

0000116604865 P

HIDAYATI
0001303327844 P MAIMON ABDUL AZIZ

0001282612871 P TONA

No
Rsp

Tgl Pel

Nama Obat

00233 03/02/2016 Gemfibrozil 300 mg

Jml
R/N Obt

Harga
Obat

23

23 191.360,00

Metformin 500 mg

46

6.624,00

00236 03/02/2016 Amlodipine 10 mg

23

9.715,20

23

17.075,20

00235 03/02/2016 Micardis 80 mg

Ramipril 5 mg

8.508,16

Harga
Diajukan

8.508

197.984

26.790

645

0001437919301 P SUHATI

00242 03/02/2016 Glimepiride 3 mg

23

11.893,76

11.894

646

0001309758546 P LUKMAN HAKIM

00243 03/02/2016 Carbamazepine 200 mg

23

7.212,80

22.198

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

647

0000773895249 P ROBIAH

00244 03/02/2016 Captopril 25 mg

69

7.418,88

7.419

648

0001048570378 P BADRIYAH

00256 03/02/2016 Micardis 80 mg

23 191.360,00

191.360

649

0000116932004 I SITI HINDUN

00259 03/02/2016 Miniaspi 80 mg

23

4.357,12

441.343

650

651

652

653

654

0000116968522 P SUMAWATI JD.HAMID

0000117079086 P MOH. SAYUDI

0001891626748 P RUHANA

0000769712387 P UVA LUSIANA

0001787915316 P SUPARLAN

Novorapid Flexpen 100 UI/ml

2 215.069,40

Diovan 80 mg

23 114.816,00

Lantus Solostar 100 UI/ml

1 107.100,00

00264 04/02/2016 Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Gemfibrozil 300 mg

23

8.508,16

23

4.357,12

Amlodipine 10 mg

23

9.715,20

00275 04/02/2016 Furosemide 40 mg

23

2.502,40

Metformin 500 mg

23

3.312,00

23

4.357,12

Furosemide 40 mg

12

1.305,60

Digoksin 0,25 mg

23

2.855,68

46

23.846,40

23

4.239,36

23

9.715,20

Herbesser CD 100 mg

23 107.956,48

Captopril 12,5 mg

69

00274 04/02/2016 Miniaspi 80 mg

00278 04/02/2016 Miniaspi 80 mg

00284 04/02/2016 Trifluoperazin 5 mg


Klorpromazin 100 mg

655

0001853161738 P WIJAYANTI

Halaman :

49

00290 04/02/2016 Amlodipine 10 mg

5.475,84

37.212

14.072

5.814

8.518

28.086

123.148

No.

No Ka Peserta

656

0000117029597 P ABD HADI

Nama

No
Rsp

Tgl Pel

Nama Obat

00296 04/02/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

657

658

659

0000774841061 P HALIMA

0000116958341 P R.ACH.MASJKUR KAMIL

0000116928696 P ACHMAD HAMBALI

661

0001429643103 P SUNA

0000116903046 P ACH.MUTTAQI, BA

Harga
Obat

1 107.534,70

1 107.100,00

00297 04/02/2016 Amitriptyline 25 mg

12

1.720,32

Haloperidol 0,5 mg

46

3.473,92

Alprazolam 0,5 mg

23

6.300,16

23

2.855,68

Berotec MDI 100 mcg/puff

91.854,00

Furosemide 40 mg

23

2.502,40

Allopurinol 300 mg

23

5.873,28

Fenofibrate 100 mg

23

31.648,00

Glibenklamide 5 mg

23

1.648,64

Metformin 500 mg

69

9.936,00

23 200.192,00

23 209.024,00

23

11.893,76

Metformin 500 mg

69

9.936,00

00313 04/02/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

00298 04/02/2016 Digoksin 0,25 mg

00300 04/02/2016 Harnal Ocas 0,4 mg


Avodart 0,5 mg

660

Jml
R/N Obt

00301 04/02/2016 Glimepiride 3 mg

Glimepiride 4 mg

Harga
Diajukan
214.635

11.494

146.318

409.216

21.830

22.595

662

0000116960501 P RIDWAN, BA

00314 04/02/2016 Allopurinol 300 mg

23

5.873,28

5.873

663

0000117282745 P DJUMAATIYAH JD SAIDI

00316 04/02/2016 Isosorbid Dinitrat 5 mg

69

7.772,16

43.380

Miniaspi 80 mg

23

4.357,12

Glicab 80 mg

46

13.895,68

Captopril 25 mg

69

7.418,88

Metformin 500 mg

69

9.936,00

23 200.192,00

23 209.024,00

23

10.304,00

Allopurinol 300 mg

23

5.873,28

Glimepiride 2 mg

23

12.835,84

664

0000774671679 P ABD.HADI

00319 04/02/2016 Harnal Ocas 0,4 mg


Avodart 0,5 mg

665

0000117034727 I SITI RAODAH

Halaman :

50

00320 04/02/2016 Lisinopril 5 mg

409.216

29.013

No.

No Ka Peserta

666

0001437498112 P ACHMAD FADALI

Nama

No
Rsp

Tgl Pel

Nama Obat

00322 04/02/2016 Miniaspi 80 mg

Jml
R/N Obt

Harga
Obat

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Gemfibrozil 300 mg

23

8.508,16

Harga
Diajukan
41.569

667

0000206765054 I MAMNUAH

00323 04/02/2016 Furosemide 40 mg

12

1.305,60

1.306

668

0001390264694 P MARYANI

00326 04/02/2016 Glimepiride 4 mg

23

12.659,20

12.659

669

0000116975147 P KAMARIYAH R.A

00329 04/02/2016 Metformin 500 mg

23

3.312,00

8.258

46

4.945,92

138

56.348,16

46

3.827,20

69

7.772,16

Furosemide 40 mg

12

1.305,60

Miniaspi 80 mg

23

4.357,12

Captopril 25 mg
670

0000776904535 P RUSTIANI

00330 04/02/2016 Propiltiourasil 100 mg


Propranolol 10 mg

671

0001339414413 P ATNA

00336 04/02/2016 Isosorbid Dinitrat 5 mg

60.175

13.435

672

0000116986342 P SITI NURHAYATI

00337 04/02/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

673

0001104261557 P SOEPRI YANTONO

00340 04/02/2016 Isosorbid Dinitrat 5 mg

69

7.772,16

12.129

Miniaspi 80 mg

23

4.357,12

674

0001048326377 P HOZAIMAH

00341 04/02/2016 Micardis 80 mg

23 191.360,00

191.360

675

0000116952041 P MOHAMAD DRADJID

00342 04/02/2016 Spiriva Refill 18 mcg

30 532.502,78

647.319

23 114.816,00

69

9.936,00

23

12.659,20

Diovan 80 mg
676

0000117064956 P TAJUL ARIFIN

00346 04/02/2016 Metformin 500 mg


Glimepiride 4 mg

677

0001270168301 P ACH.KUSWANDI

00407 04/02/2016 Top Up Hemofilia RS B Reg I NULL

678

0001082445546 P SRIYATI

00348 05/02/2016 Furosemide 40 mg

1 7.914.200,0
0
12
1.305,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Miniaspi 80 mg

23

4.357,12

00356 05/02/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

4.357,12

23

5.505,28

679

680

0000777728834 P IDA WATI

0001104491619 P YUDI SANTOSO

00362 05/02/2016 Miniaspi 80 mg


Amlodipine 5 mg

Halaman :

51

22.595

7.914.200
13.435

14.985

9.862

No.

No Ka Peserta

681

0000114937323 P ACHMAD SURJANTO

682

683

Nama

0001410087082 P MUNAMI

0001048545955 P LENI IRAWATI

No
Rsp

Tgl Pel

Nama Obat

00372 05/02/2016 Miniaspi 80 mg

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Allopurinol 100 mg

23

2.531,84

Metformin 500 mg

69

9.936,00

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

23

12.659,20

12.659
322.169

00378 05/02/2016 Amlodipine 10 mg

00379 05/02/2016 Miniaspi 80 mg

684

0001379620708 P SILVANA TANI

00380 05/02/2016 Glimepiride 4 mg

685

0001859563596 P NURIYAMI

00382 05/02/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

1 107.100,00

Lantus Solostar 100 UI/ml

21.844

34.077

21.844

686

0001104294576 P MOCH.SALEH

00384 05/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

687

0000117106604 P ERIE HARIYANTO

00387 05/02/2016 Amlodipine 10 mg

23

9.715,20

124.531

Micardis 40 mg

23 114.816,00

00392 05/02/2016 Miniaspi 80 mg

23

4.357,12

Furosemide 40 mg

12

1.305,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Captopril 25 mg

69

7.418,88

00393 06/02/2016 Micardis 80 mg

16 133.120,00

Concor 2,5 mg

23

21.962,24

00400 06/02/2016 Furosemide 40 mg

23

2.502,40

Allopurinol 300 mg

23

5.873,28

Captopril 25 mg

69

7.418,88

00401 06/02/2016 Thyrozol 10 mg

46

66.828,80

46

3.827,20

688

689

690

691

0000117021082 P ABDUL MAHWAR

0000208493886 I HAMIDAH

0000116998615 P MOCH NAWAWI

0001318125262 P NURUL ANISYAH

Propranolol 10 mg
692

0000778973962 P MOHAMMAD NUR

00408 06/02/2016 Novorapid Flexpen 100 UI/ml

693

0001845099123 P DURRIYAH

00409 06/02/2016 Glimepiride 3 mg

Halaman :

52

20.854

155.082

15.795

70.656

4 430.138,80

430.139

11.893,76

11.894

23

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

694

0000775067016 P LIPAH

00415 06/02/2016 Phenytoin 100 mg

69

11.746,56

11.747

695

0000116952399 P MOHAMMAD ABDULLAH

00416 06/02/2016 Metformin 500 mg

69

9.936,00

22.595

23

12.659,20

Nama

Tgl Pel

Nama Obat

Glimepiride 4 mg
696

0000775128879 P MOTRO

00419 06/02/2016 Levopar 125 mg komb

46

88.320,00

88.320

697

0000116714171 P SRI WAHYUNI

00420 06/02/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

698

0001269442089 P INTAN TRI LESTARI

00421 06/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

699

0000116983607 P JUNAIDI

00422 06/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

700

0000117125616 P SRI HARTINI

00425 06/02/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

701

0000116984439 P MOH ERFAN

00426 06/02/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

702

0000116981098 P AKHMAD NAJIRUDIN

00427 06/02/2016 Glimepiride 3 mg

23

11.893,76

43.542

23

31.648,00

39

56.659,20

69

5.740,80

Fenofibrate 100 mg
703

0000774684325 P ANDRIYANI

00429 06/02/2016 Thyrozol 10 mg


Propranolol 10 mg

62.400

704

0001662375993 P SITI MUFTIRAH

00433 06/02/2016 Glimepiride 3 mg

23

11.893,76

11.894

705

0000117050062 P MOH SJAIFUL EFENDI

00435 06/02/2016 Metformin 500 mg

69

9.936,00

80.886

Akarbose 100 mg

46

58.291,20

Glimepiride 4 mg

23

12.659,20

00439 06/02/2016 Glimepiride 3 mg

23

11.893,76

23

17.664,00

46

13.895,68

Metformin 850 mg

46

11.628,80

Akarbose 100 mg

46

58.291,20

706

0000173117665 I RISKIATIN

Lisinopril 10 mg
707

0000116779544 P RADEN AYU SRI


KARTININGSIH

00442 06/02/2016 Glicab 80 mg

29.558

83.816

708

0001410409552 P INDAH LESTARI K

00445 06/02/2016 Phenytoin 100 mg

69

11.746,56

11.747

709

0000779511464 P SUGIANTO

00446 06/02/2016 Lisinopril 10 mg

23

17.664,00

29.440

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

710

0001801424766 P NOVA RISKIYAH

00447 06/02/2016 Phenytoin 100 mg

69

11.746,56

11.747

711

0000116992427 P MAS`AT

00448 06/02/2016 Glimepiride 3 mg

23

11.893,76

70.185

Akarbose 100 mg

46

58.291,20

Halaman :

53

No.

No Ka Peserta

712

0002034135101 P MOH. ASMONI

Nama

No
Rsp

Tgl Pel

Nama Obat

00451 06/02/2016 Amlodipine 10 mg


Lisinopril 10 mg

Jml
R/N Obt

Harga
Obat

23

9.715,20

23

17.664,00

Harga
Diajukan
27.379

713

0000172349785 1 IRA ANGGRAINI

00455 06/02/2016 Symbicort 80/4.5mcg

1 139.230,00

139.230

714

0001874550014 P SULALAH

00460 06/02/2016 Novorapid Flexpen 100 UI/ml

1 107.534,70

214.635

1 107.100,00

Lantus Solostar 100 UI/ml


715

0000780402251 P AGUS

00462 06/02/2016 Top Up Hemofilia RS B Reg I NULL

716

0000117071087 P RUDY SETIAWAN

00464 06/02/2016 Olandoz 10 10 mg

1 7.914.200,0
0
23 329.728,00

Alprazolam 1 mg

23

6.859,52

Risperidon 2 mg

46

59.351,04

23 329.728,00

Merlopam 2 mg

23

39.479,04

Alprazolam 1 mg

23

6.859,52

11,5

73.600,00

23

4.239,36

11,5

1.648,64

11,5

3.150,08

23

3.297,28

16

4.382,72

23

17.664,00

23

12.659,20

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Lantus Solostar 100 UI/ml

Allopurinol 300 mg

23

5.873,28

717

718

0000202346032 P SAKDIJAH

0000116673221 P SITI KIPIYAH

00465 06/02/2016 Olandoz 10 10 mg

00466 06/02/2016 Clorilex 100 100 mg


Klorpromazin 100 mg

719

0000116559944 P MUHAMAD TRISWARNO

00470 06/02/2016 Amitriptyline 25 mg


Alprazolam 0,5 mg

720

0000116984709 P MOHAMMAD RIDA`I

00474 06/02/2016 Amitriptyline 25 mg


Alprazolam 0,5 mg

721

0000117028089 P SULISTINA

00475 06/02/2016 Lisinopril 10 mg


Glimepiride 4 mg

722

0000099722092 P KASMAN

00459 08/02/2016 Miniaspi 80 mg

7.914.200
395.939

376.067

77.839

4.799

7.680

30.323

144.710

1 107.100,00

723

0000779286407 P SAPRAWI

00486 09/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

724

0000100712608 P M FAUZI HOSNI

00487 09/02/2016 Captopril 12,5 mg

69

5.475,84

5.476

725

0000117495909 P SALIM B HUBAIS

00488 09/02/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

422.265

23 100.096,00

Clopidogrel 75 mg

Halaman :

54

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Lantus Solostar 100 UI/ml

726

0000117093363 P BUNAMIN

00494 09/02/2016 Amlodipine 5 mg

0001795026993 P MOHAMMAD HASAN

5.505,28

46

4.945,92

23

5.505,28

69

7.418,88

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Gemfibrozil 300 mg

23

8.508,16

Allopurinol 100 mg

23

2.531,84

00498 09/02/2016 Amlodipine 5 mg

0000117079659 P DJIMRON HARDIANTO

00500 09/02/2016 Amlodipine 10 mg

Harga
Diajukan

1 107.100,00
23

Captopril 25 mg
728

Harga
Obat

Captopril 25 mg
727

Jml
R/N Obt

10.451

12.924

38.419

729

0000775311671 P SUSMIYATI

00501 09/02/2016 Glimepiride 4 mg

23

12.659,20

12.659

730

0001385196142 P TEDI RIAN HANDIKA

00502 09/02/2016 Vitamin B6 10 mg

23

3.238,40

14.985

Phenytoin 100 mg

69

11.746,56

23

4.357,12

Amlodipine 5 mg

23

5.505,28

731

0000775990506 P HATIB

00507 09/02/2016 Miniaspi 80 mg

9.862

732

0000116935661 P H. ABDUL MUGID

00515 09/02/2016 Glimepiride 3 mg

23

11.893,76

11.894

733

0000116997636 P MOH. SAHRI

00516 09/02/2016 Amlodipine 10 mg

23

9.715,20

152.515

Seretide Diskus 250 250 mcg/puff


734

735

0001295565377 P SIRAD

0001479470275 P SUMIATI

00517 09/02/2016 Spironolacton 25 mg

737

0001325427355 P HAFIFAH

0000777427301 P SAFATUN

23

9.273,60

Berotec MDI 100 mcg/puff

91.854,00

Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

12

8.908,80

23

33.414,40

23

1.913,60

23

17.664,00

00522 09/02/2016 Thyrozol 10 mg

00523 09/02/2016 Lisinopril 10 mg


Novorapid Flexpen 100 UI/ml

Furosemide 40 mg

Lantus Solostar 100 UI/ml

2 214.200,00

23 191.360,00

69

00527 09/02/2016 Micardis 80 mg


Metformin 500 mg

Halaman :

55

1 142.799,58

Propranolol 10 mg
736

112.539

35.328

664.505

4 430.138,80
23

2.502,40

9.936,00

201.296

No.

No Ka Peserta

738

0001795802398 P FAJARIYAH MULYANI

739

Nama

0000114179962 P ABD. KAHIR

No
Rsp

Tgl Pel

Nama Obat

00532 09/02/2016 Furosemide 40 mg

741

742

743

0001876227254 P MA.SYAKUR

0000777677567 P PUANI

0001100805759 P DWI ENGGAL


SULISTYORINI

0000777983501 P FAISAL

Harga
Obat

23

Micardis 80 mg

23 191.360,00

Bisoprolol 5 mg

23

18.988,80

23

12.659,20

69

9.936,00

23 191.360,00

Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

23

9.273,60

Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

12

8.908,80

23

12.835,84

Metformin 500 mg

69

9.936,00

Allopurinol 100 mg

23

2.531,84

23

18.988,80

23

9.715,20

00533 09/02/2016 Glimepiride 4 mg


Metformin 500 mg

740

Jml
R/N Obt

00534 09/02/2016 Micardis 80 mg

00548 09/02/2016 Spironolacton 25 mg

00549 09/02/2016 Glimepiride 2 mg

00550 09/02/2016 Bisoprolol 5 mg


Amlodipine 10 mg

2.502,40

Harga
Diajukan
212.851

22.595

203.578

20.685

25.304

28.704

744

0002034135101 P MOH. ASMONI

00565 09/02/2016 Allopurinol 100 mg

23

2.531,84

2.532

745

0001048406679 P TUMA

00572 09/02/2016 Glimepiride 4 mg

23

12.659,20

22.595

Metformin 500 mg

69

9.936,00

00575 09/02/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

00576 09/02/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

746

0000774509286 P BUANI

Glimepiride 4 mg
747

0001155718539 P ISMAIL

22.595

14.985

748

0000116970671 I SITI SUPARMI

00577 09/02/2016 Captopril 25 mg

69

7.418,88

7.419

749

0000776679142 P MARDIYANA

00578 09/02/2016 Bisoprolol 5 mg

12

9.907,20

21.683

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

750

0000116970647 P UDDIN

00580 09/02/2016 Seretide Diskus 250 250 mcg/puff

751

0000770009545 P SAKUJI

00589 09/02/2016 Thyrozol 10 mg

Halaman :

56

1 142.799,58

142.800

33.414,40

35.328

23

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Propranolol 10 mg

752

0000116987782 P UMI FATIROH

00590 09/02/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

Jml
R/N Obt
N

23

Harga
Obat

Harga
Diajukan

1.913,60

5 537.673,50

2 214.200,00
1 142.799,58

142.800
28.851

753

0000116912676 P MOH.ALI NITISASTRO

00591 09/02/2016 Seretide Diskus 250 250 mcg/puff

754

0000203035138 I SITI NAWARAH

00592 09/02/2016 Furosemide 40 mg

23

2.502,40

Ramipril 5 mg

23

17.075,20

Spironolacton 25 mg

23

9.273,60

755

0001313587462 P TOYANI

00598 09/02/2016 Seretide Diskus 250 250 mcg/puff

756

0000195147404 I MARWATI

00600 09/02/2016 Amlodipine 10 mg

Lisinopril 10 mg
Allopurinol 100 mg

751.874

1 142.799,58

142.800

23

9.715,20

29.911

23

17.664,00

23

2.531,84

757

0000774957047 P SAHRIYAH

00601 09/02/2016 Amlodipine 5 mg

23

5.505,28

5.505

758

0001871901257 P SATRAEH

00602 09/02/2016 Miniaspi 80 mg

23

4.357,12

31.324

Furosemide 40 mg

23

2.502,40

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Captopril 25 mg

69

7.418,88

00616 09/02/2016 Thyrozol 10 mg

23

33.414,40

23

1.913,60

23

33.414,40

23

1.913,60

759

0000775208395 P MOH.FARDI

Propranolol 10 mg
760

0000774566379 P SAMIYAH

00621 09/02/2016 Thyrozol 10 mg


Propranolol 10 mg

761

0000775698221 P SUMIH

00632 10/02/2016 Symbicort 80/4.5mcg

762

0000116988502 I SUTAN TINAH

00652 10/02/2016 Metformin 500 mg

Lantus Solostar 100 UI/ml


763

0001427443132 P AINUR RIDWAN

00654 10/02/2016 Furosemide 40 mg

0001453212156 P FAISOL

Halaman :

57

35.328

1 139.230,00

139.230

6.624,00

113.724

46

1 107.100,00

23

2.502,40

23

20.608,00

00657 10/02/2016 Furosemide 40 mg

23

2.502,40

Amlodipine 10 mg

23

9.715,20

Kalipar 300 mg

23

20.608,00

Kalipar 300 mg
764

35.328

23.110

32.826

No.

No Ka Peserta

765

0000775055158 P SULIHA

766

767

Nama

0001484512312 P MOH.SUUDDIN

0000117941286 S HUSIANSENG

No
Rsp

Tgl Pel

Nama Obat

00659 10/02/2016 Amlodipine 10 mg

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Bisoprolol 5 mg

23

18.988,80

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

23 191.360,00

Metformin 500 mg

23

3.312,00

00670 10/02/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

23

16.574,72

16.575

00664 10/02/2016 Micardis 80 mg

Glimepiride 4 mg

58.144

194.672

22.595

768

0000116734825 I ENDANG HASTUTIK

00671 10/02/2016 Thyrozol 5 mg

769

0000117130421 P SUPARMAN

00673 10/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

770

0000116878162 P SUPRAPTI

00675 10/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

771

0001410845848 P HARIS BURHAN

00676 10/02/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

772

0000116734206 P HASYIRULLAH

00677 10/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

773

0000198713158 I SALIMAH

00678 10/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

774

0001081852165 P SELFIA

00686 10/02/2016 Thyrozol 10 mg

23

33.414,40

33.414

775

0001270096468 P SITTI RAMLAH

00690 10/02/2016 Miniaspi 80 mg

23

4.357,12

5.663

12

1.305,60

23

11.893,76

Metformin 500 mg

69

9.936,00

00693 10/02/2016 Allopurinol 300 mg

23

5.873,28

Micardis 80 mg

23 191.360,00

Gemfibrozil 300 mg

23

23 191.360,00

Glimepiride 3 mg

23

11.893,76

Gemfibrozil 300 mg

23

8.508,16

Allopurinol 300 mg

23

5.873,28

Furosemide 40 mg
776

777

778

779

0000196656726 I SUNIYAH

0000147812038 P ABU HASAN, A.PRA.TTD

0000116983528 P JUHAIRIYAH

0001304829246 P AMIN FAIZ

00692 10/02/2016 Glimepiride 3 mg

00695 10/02/2016 Micardis 80 mg

00707 10/02/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

Halaman :

58

21.830

205.741

8.508,16

2 215.069,40

1 107.100,00

217.635

322.169

No
Rsp

Jml
R/N Obt

No.

No Ka Peserta

780

0000116983304 P INDAH MASWIYATI

00709 10/02/2016 Seretide Diskus 100 100 mcg/puff

781

0000774626253 P MASSORI

00711 10/02/2016 Furosemide 40 mg

Allopurinol 300 mg

Nama

Tgl Pel

Nama Obat

Harga
Obat

Harga
Diajukan

1 127.049,58

127.050

12

1.305,60

7.179

23

5.873,28

782

0001266538487 P LISNAWATI

00712 10/02/2016 Captopril 50 mg

69

12.364,80

12.365

783

0000774371428 P ASBUNA

00716 10/02/2016 Miniaspi 80 mg

23

4.357,12

17.016

23

12.659,20

23

8.508,16

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

46

14.425,60

69

11.746,56

Glimepiride 4 mg
784

785

0000162146643 P HARI YANTO, S.H.I

0000197467569 1 NURCHOLIS SETIAWAN


ALI

00717 10/02/2016 Gemfibrozil 300 mg

00731 11/02/2016 Carbamazepine 200 mg


Phenytoin 100 mg

30.338

26.172

786

0000169910662 I ANIFATUR RAHMAH

00732 11/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

787

0000116824656 P RADEN HANAFI


HENDRAJANA
0000116981572 P BAMBANG IRIYANTO

00736 11/02/2016 Levopar 125 mg komb

69 132.480,00

132.480

00741 11/02/2016 Amlodipine 10 mg

23

9.715,20

22.551

23

12.835,84

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Captopril 25 mg

69

7.418,88

788

Glimepiride 2 mg
789

0001338216063 P MOCH.RIDWAN

00747 11/02/2016 Miniaspi 80 mg

21.491

790

0000775656178 P MISKIYAH

00748 11/02/2016 Bisoprolol 5 mg

23

18.988,80

18.989

791

0000116926637 P ABD.KADIR

00749 11/02/2016 Glicab 80 mg

46

13.895,68

23.832

69

9.936,00

23

4.357,12

69

7.772,16

23

11.893,76

69

9.936,00

Metformin 500 mg
792

0001855284208 P HOLILAH

00751 11/02/2016 Miniaspi 80 mg


Isosorbid Dinitrat 5 mg

793

0000142684119 P DJOKO WIDODO

00756 11/02/2016 Glimepiride 3 mg


Metformin 500 mg

12.129

21.830

794

0000775479273 P HOTIMAH

00758 11/02/2016 Thyrozol 10 mg

23

33.414,40

33.414

795

0001195095767 P INTAN RAHMAWATI

00761 11/02/2016 Amitriptyline 25 mg

23

3.297,28

13.071

Haloperidol 0,5 mg

46

3.473,92

Alprazolam 0,5 mg

23

6.300,16

46 164.451,84

796

0000116841508 P NOOR FATIMATUS

Halaman :

59

00762 11/02/2016 Depakote ER 250 mg

223.803

No.
796

No Ka Peserta
0000116841508 P

Nama
ZACHRAH

No
Rsp

Tgl Pel

Nama Obat

00762 11/02/2016 Depakote ER 250 mg

798

0000116983765 P LIDIAWATY YOHANA


KAISIRI
0000778563685 P IMAM MA'RUF

Harga
Obat

Harga
Diajukan

46 164.451,84

46

00765 11/02/2016 Micardis 80 mg

23 191.360,00

191.360

00768 11/02/2016 Allopurinol 300 mg

23

5.873,28

7.522

23

1.648,64

Risperidon 2 mg
797

Jml
R/N Obt

Glibenklamide 5 mg

223.803

59.351,04

799

0001048471029 P RISKIADI P.

00769 11/02/2016 Furosemide 40 mg

12

1.305,60

1.306

800

0001094091748 P ABD.KARIM

00770 11/02/2016 Harnal Ocas 0,4 mg

23 200.192,00

409.216

23 209.024,00

46

45.926,40

Glicab 80 mg

46

13.895,68

Metformin 500 mg

69

9.936,00

00777 11/02/2016 Allopurinol 300 mg

23

5.873,28

Metformin 500 mg

23

3.312,00

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Kalipar 300 mg

23

20.608,00

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Avodart 0,5 mg
801

802

803

804

0000117122962 P A SUGIANTO

0000116804226 P ALI SADIKIN

0000775655493 P MISKADI

0001823203765 P MOH.SHOLEH

00771 11/02/2016 Akarbose 50 mg

00781 11/02/2016 Miniaspi 80 mg

00783 11/02/2016 Isosorbid Dinitrat 5 mg

805

0000780212463 P ACH.SAUKI

00784 11/02/2016 Top Up Hemofilia RS B Reg I NULL

806

0000116896094 P BAIDAI

00793 11/02/2016 Harnal Ocas 0,4 mg

1 7.914.200,0
0
23 200.192,00

23 209.024,00

46

3.827,20

23

16.574,72

23

11.893,76

69

9.936,00

23

11.893,76

23

8.508,16

23

17.664,00

23

21.962,24

Avodart 0,5 mg
807

0000775526951 P NATIFAH

00801 11/02/2016 Propranolol 10 mg


Thyrozol 5 mg

808

0000116890402 P SITI MUTMAINAH

00802 11/02/2016 Glimepiride 3 mg


Metformin 500 mg

809

0000116966046 I SITI ROCHANI

00803 11/02/2016 Glimepiride 3 mg


Gemfibrozil 300 mg

810

0000116966035 P SOEGI PRABOWO

00804 11/02/2016 Lisinopril 10 mg


Concor 2,5 mg

Halaman :

60

69.758

9.185

35.240

12.129

7.914.200
409.216

20.402

21.830

20.402

39.626

No.

No Ka Peserta

811

0001423361586 P YUK AMALIA

Nama

No
Rsp

Tgl Pel

Nama Obat

00805 11/02/2016 Glimepiride 2 mg

Jml
R/N Obt

Harga
Obat

23

12.835,84

Metformin 500 mg

46

6.624,00

Harga
Diajukan
19.460

812

0001389542163 P ELLY FRIAH NINGSIH

00810 11/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

813

0001282144184 P JUMA'I

00811 11/02/2016 Miniaspi 80 mg

23

4.357,12

19.548

Isosorbid Dinitrat 5 mg

69

7.772,16

Captopril 25 mg

69

7.418,88

814

0000116984193 P MAZHAR

00812 11/02/2016 Diovan 80 mg

23 114.816,00

114.816

815

0000116811742 I AGUSTINA WATI

00814 11/02/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

215.069

816

0000774043244 P MAHMUDI

00830 12/02/2016 Vitamin B6 10 mg

23

3.238,40

19.931

Captopril 25 mg

46

4.945,92

Phenytoin 100 mg

69

11.746,56

00832 12/02/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

33.414,40

46

3.827,20

23 161.920,00

23

8.508,16

817

818

0001478151909 P SAFIK

0001048377284 P HAZIZAH

00844 12/02/2016 Thyrozol 10 mg


Propranolol 10 mg

819

0001810491715 P KUTSIYAH WICITRO

00845 12/02/2016 Gliclazide 60 mg


Gemfibrozil 300 mg

14.985

37.242

170.428

820

0000081429074 I SITI MARFATI

00856 12/02/2016 Captopril 25 mg

69

7.418,88

7.419

821

0000116981965 I AMANIYAH

00857 12/02/2016 Micardis 80 mg

23 191.360,00

213.955

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

822

0000776677522 P M RUJI

00867 12/02/2016 Diovan 80 mg

23 114.816,00

114.816

823

0001048339304 P MAS AH

00868 12/02/2016 Metformin 500 mg

69

9.936,00

9.936

824

0000774902891 P SITI NUR SATRIA

00870 12/02/2016 Propranolol 10 mg

46

3.827,20

32.001

69

28.174,08

23

9.715,20

9.715

1 139.230,00

139.230
70.656

Propiltiourasil 100 mg
825

0000775264779 P BUSIYAH

00875 12/02/2016 Amlodipine 10 mg

826

0001322380585 P DEWI IRAWATI

00876 12/02/2016 Symbicort 80/4.5mcg

827

0000775628436 P MUSARROFAH

00883 13/02/2016 Thyrozol 10 mg

46

66.828,80

46

3.827,20

Propranolol 10 mg

Halaman :

61

No
Rsp

Jml
R/N Obt

No.

No Ka Peserta

828

0000117516161 P SUSI AGUSTIN, AMA.PD

00894 13/02/2016 Seretide Diskus 100 100 mcg/puff

829

0000117029485 I ROFIATUS SYARIFAH

00895 13/02/2016 Amlodipine 10 mg

Metformin 500 mg
Glimepiride 4 mg
830

Nama

0000116852444 P SAHURI

Tgl Pel

Nama Obat

00899 13/02/2016 Amlodipine 10 mg


Novorapid Flexpen 100 UI/ml

831

832

127.050

23

9.715,20

32.310

69

9.936,00

23

12.659,20

23

9.715,20

23

Micardis 80 mg

23 191.360,00

Isosorbid Dinitrat 5 mg

69

00901 13/02/2016 Lantus Solostar 100 UI/ml

0000775228105 P FADILAH

00904 13/02/2016 Thyrozol 5 mg


Propranolol 10 mg

46

33.149,44

46

3.827,20

835

0000116900245 I SUHENAH

00917 13/02/2016 Amlodipine 10 mg

837

0001328188138 P MOCH.RIDA'I

119.936

36.977

1 127.049,58

127.050

23

9.715,20

22.551

23

12.835,84

23 191.360,00

Amlodipine 10 mg

23

9.715,20

00919 13/02/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

Akarbose 100 mg

46

58.291,20

Glimepiride 2 mg
0001328189646 P SUNAR HAYATI

1 107.100,00
12.835,84

00905 13/02/2016 Seretide Diskus 100 100 mcg/puff

203.489

7.772,16

23

0000196300912 I IDA FARIDA YUNAIDI

836

4.357,12

834

332.319

3 322.604,10

0000094685084 I SRI SUNINGSIH

Harga
Diajukan

1 127.049,58

0000116986509 P SITTI ROKAYYAH NASIR 00900 13/02/2016 Miniaspi 80 mg

Glimepiride 2 mg
833

Harga
Obat

00918 13/02/2016 Micardis 80 mg

201.075

90.602

838

0000172609029 1 ABDUR ROHMAN

00923 13/02/2016 Gemfibrozil 300 mg

23

8.508,16

8.508

839

0001080688994 P BUNADJI

00924 13/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

840

0000098119484 P SUDARTO

00925 13/02/2016 Captopril 25 mg

69

7.418,88

7.419

841

0001048521521 P HADIRI

00926 13/02/2016 Glimepiride 2 mg

23

12.835,84

22.772

Metformin 500 mg

69

9.936,00

00928 13/02/2016 Amlodipine 10 mg

23

9.715,20

23

10.304,00

842

0000116981313 P ARSIDI

Lisinopril 5 mg

Halaman :

62

20.019

No.

No Ka Peserta

843

0000116906613 I SUPATYA

844

Nama

0000116878691 P HJ.SANIJAH

No
Rsp

Tgl Pel

Nama Obat

00929 13/02/2016 Glicab 80 mg

Jml
R/N Obt

Harga
Obat

46

13.895,68

Metformin 500 mg

69

9.936,00

00939 13/02/2016 Amlodipine 10 mg

23

9.715,20

69

7.418,88

Captopril 25 mg

Harga
Diajukan
23.832

17.134

845

0000116846921 P JUNAIDAH, S.SOS

00940 13/02/2016 Thyrozol 5 mg

23

16.574,72

16.575

846

0001895351286 P MOH.HASAN

00941 13/02/2016 Clorilex 100 100 mg

23 147.200,00

157.092

Klorpromazin 100 mg

23

4.239,36

Haloperidol 5 mg

46

5.652,48

46 164.451,84

Clorilex 100 100 mg

23 147.200,00

Klorpromazin 100 mg

35

6.451,20

847

0000116934917 P FADLI

00945 13/02/2016 Depakote ER 250 mg

318.103

848

0000117369617 P ACHMAD AS'AD

00946 13/02/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

849

0001895626462 P SUKARLANA

00947 13/02/2016 Ramipril 5 mg

23

17.075,20

29.734

23

12.659,20

Glimepiride 4 mg
850

0000116985734 P RIFATUN

00948 13/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

851

0000772624089 P PUSIHA

00949 13/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

852

0000774578654 P NUR FADILAH

00953 15/02/2016 Alprazolam 0,5 mg

16

4.382,72

384.159

46 379.776,00

23

6.947,84

Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

23

8.508,16

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

23

11.893,76

69

9.936,00

Olandoz 5 5 mg
853

854

855

0000116985126 I SUTJI AMINGSIH

0000117508195 I SAHAMI

0000117508184 P SUHARSO

00954 15/02/2016 Glicab 80 mg

00959 15/02/2016 Gemfibrozil 300 mg

00960 15/02/2016 Glimepiride 3 mg


Metformin 500 mg

856

0000116960196 P RAMLAH

Halaman :

63

00981 15/02/2016 Novorapid Flexpen 100 UI/ml

3 322.604,10

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

34.327

31.103

21.830

345.199

No.

No Ka Peserta

857

0000775014581 P MARROH

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

00985 15/02/2016 Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

11

9.081,60

Furosemide 40 mg

11

1.196,80

858

0001315159424 P KHAIRUL UMAMAH

00986 15/02/2016 Symbicort 80/4.5mcg

859

0000774915941 P SUPATMA

00990 15/02/2016 Miniaspi 80 mg

Bisoprolol 5 mg

860

0001048397218 P SURAHMI

Harga
Obat

139.230

23

4.357,12

23.909

11

9.081,60

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

11

1.196,80

00991 15/02/2016 Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

46

33.149,44

33.149

1 142.799,58

142.800
21.830

0000775363781 P MOH.HARIRI

00992 15/02/2016 Thyrozol 5 mg

862

0001896757402 P MARYAMAH

00993 15/02/2016 Seretide Diskus 250 250 mcg/puff

863

0000116978411 P LIMANI

00999 15/02/2016 Glimepiride 3 mg

23

11.893,76

69

9.936,00

23

33.414,40

46

3.827,20

23

33.414,40

23

1.913,60

23 161.920,00

23

Metformin 500 mg
0000774203692 P HAMIDAH

01002 15/02/2016 Thyrozol 10 mg


Propranolol 10 mg

865

0000773893991 P MARSUDAH

01003 15/02/2016 Thyrozol 10 mg


Propranolol 10 mg

866

0000116816016 P SUPARMAN

14.636

1 139.230,00

861

864

Harga
Diajukan

01004 15/02/2016 Gliclazide 60 mg


Gemfibrozil 300 mg

32.310

37.242

35.328

170.428

8.508,16

867

0000116667459 I FATWAH

01008 15/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

868

0001881531573 P A.JALALUDDIN

01012 15/02/2016 Micardis 80 mg

23 191.360,00

201.075

23

9.715,20

23

17.664,00

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

23

17.664,00

23

9.715,20

Amlodipine 10 mg
869

870

0000975930085 I SUNARTI

0001443797291 P MUTMAINNAH

01022 15/02/2016 Lisinopril 10 mg

01023 15/02/2016 Lisinopril 10 mg


Amlodipine 10 mg

Halaman :

64

40.259

27.379

No.

No Ka Peserta

871

0001304457513 P JUMANI

Nama

No
Rsp

Tgl Pel

Nama Obat

01035 15/02/2016 Seretide Diskus 250 250 mcg/puff

Jml
R/N Obt
N

Harga
Obat

1 142.799,58

Bisoprolol 5 mg

23

18.988,80

Spironolacton 25 mg

23

9.273,60

Clopidogrel 75 mg

23 100.096,00

Harga
Diajukan
271.158

872

0000098228834 P ABD. KAMAR

01044 15/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

873

0000116883764 I KOESTINAH

01045 16/02/2016 Glimepiride 3 mg

23

11.893,76

168.294

Diovan 80 mg

23 114.816,00

Fenofibrate 100 mg

23

31.648,00

Metformin 500 mg

69

9.936,00

874

0001311944365 P ATIYEH

01056 16/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

875

0000209712251 P SURATININGSIH

01058 16/02/2016 Amlodipine 10 mg

23

9.715,20

439.541

876

0000116833915 P MOH. HAKI

Novomix Flexpen 100 UI/ml

Akarbose 100 mg

23

29.145,60

23

4.357,12

46

4.945,92

01065 16/02/2016 Miniaspi 80 mg


Captopril 25 mg

3 400.680,00

9.303

877

0000159399516 P SITI SUPRAPTI

01066 16/02/2016 Micardis 80 mg

23 191.360,00

191.360

878

0000116954616 P MUZAKKI

01069 16/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

879

0001094091772 P ABDUS SUUD

01075 16/02/2016 Akarbose 50 mg

23

22.963,20

165.836

Spironolacton 25 mg

23

9.273,60

Herbesser CD 100 mg

23 107.956,48

Furosemide 40 mg

23

2.502,40

Glimepiride 2 mg

23

12.835,84

Lisinopril 5 mg

23

10.304,00

23

17.664,00

23

2.502,40

23

5.505,28

Lisinopril 10 mg

23

17.664,00

01082 16/02/2016 Micardis 80 mg

23 191.360,00

23

880

0000116991753 P MOHAMMAD JUFFRI

01077 16/02/2016 Lisinopril 10 mg


Furosemide 40 mg

881

882

0001291903301 P AGUSTINA SAID


WACHDIN

0000776138859 P HALIFAH

01078 16/02/2016 Amlodipine 5 mg

Amlodipine 10 mg

Halaman :

65

9.715,20

20.166

23.169

203.578

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Furosemide 40 mg

883

0000776857149 P SU'UD

Jml
R/N Obt

Harga
Obat

23

2.502,40

23

4.357,12

Levopar 125 mg komb

46

88.320,00

Diovan 80 mg

23 114.816,00
1 142.799,58

142.800
164.644

01083 16/02/2016 Miniaspi 80 mg

884

0001961579406 P MUSARAH

01086 16/02/2016 Seretide Diskus 250 250 mcg/puff

885

0001279734884 P EKO MARDIONO

01092 16/02/2016 Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Seretide Diskus 250 250 mcg/puff

Isosorbid Dinitrat 5 mg

69

7.772,16

01100 16/02/2016 Gemfibrozil 300 mg

23

8.508,16

Glibenklamide 5 mg

46

3.297,28

Metformin 500 mg

46

6.624,00

23

4.357,12

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

23 161.920,00

46

6.624,00

23

4.357,12

23

5.505,28

886

887

888

0000164418243 I HJ. UMMUL KARIMAH

0000116926244 P ABD. SAMAD, A.MA

0000116926255 I MUSLIMAH

01101 16/02/2016 Miniaspi 80 mg

01102 16/02/2016 Gliclazide 60 mg


Metformin 500 mg

889

0000116852444 P SAHURI

Harga
Diajukan

01107 16/02/2016 Miniaspi 80 mg


Amlodipine 5 mg

207.493

1 142.799,58

18.429

21.403

168.544

9.862

890

0000117040645 P PADDUS

01117 16/02/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

891

0000117061784 P MOH SUGIANTO

01118 16/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

892

0000776728045 P MARYANI

01124 16/02/2016 Metformin 500 mg

69

9.936,00

22.595

23

12.659,20

23

7.212,80

Phenytoin 100 mg

69

11.746,56

Vitamin B6 10 mg

23

3.238,40

23

7.212,80

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

Glimepiride 4 mg
893

894

0000777784127 P SUBAIRI

0000775174612 P ABD RAHMAN

Halaman :

66

01132 17/02/2016 Carbamazepine 200 mg

01140 17/02/2016 Carbamazepine 200 mg

22.198

22.198

No
Rsp

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

No.

No Ka Peserta

895

0000117017785 P ABD RAHMAN

01150 17/02/2016 Glimepiride 2 mg

23

12.835,84

12.836

896

0000775898155 P MISPARI

01155 17/02/2016 Thyrozol 10 mg

23

33.414,40

35.328

23

1.913,60

16

8.806,40

Metformin 500 mg

69

9.936,00

Nama

Tgl Pel

Nama Obat

Propranolol 10 mg
897

0000776569184 P HOTIJA

01157 17/02/2016 Glimepiride 4 mg

18.742

898

0001266413264 P KOMARIYATUN

01159 17/02/2016 Propranolol 40 mg

23

3.150,08

3.150

899

0001315837348 P MOSLEH

01160 17/02/2016 Miniaspi 80 mg

23

4.357,12

4.357

900

0001839722771 P SULIHA

01162 17/02/2016 Miniaspi 80 mg

23

4.357,12

18.003

Allopurinol 300 mg

23

5.873,28

Isosorbid Dinitrat 5 mg

69

7.772,16

23

17.664,00

23

12.659,20

23

4.357,12

Amlodipine 5 mg

23

5.505,28

Isosorbid Dinitrat 5 mg

69

7.772,16

11

70.400,00

46

98.918,40

46

59.351,04

32.000,00

901

0001277060725 P SUFRI DJAJADI TAFRI

01165 17/02/2016 Lisinopril 10 mg


Glimepiride 4 mg

902

903

0000776314214 P TIPYAN

0000977368588 S ABRAHAM AJIE

01166 17/02/2016 Miniaspi 80 mg

01169 17/02/2016 Clorilex 100 100 mg


Depakote 250 mg

904

0000774393614 P GUNAWAN AGUS


SUSANTO

01172 17/02/2016 Risperidon 2 mg


Clorilex 100 100 mg

30.323

17.635

169.318

91.351

905

0000775630787 P MUSLIHAH

01176 17/02/2016 Glimepiride 4 mg

16

8.806,40

8.806

906

0000116958802 P R.M.ISKANDAR
MIFTAH,SH

01178 17/02/2016 Metformin 850 mg

46

11.628,80

21.344

Amlodipine 10 mg

23

9.715,20

23

33.414,40

23

1.913,60

907

0000776340729 P PIHA

01179 17/02/2016 Thyrozol 10 mg


Propranolol 10 mg

35.328

908

0000777041965 P MURA'E

01180 17/02/2016 Isosorbid Dinitrat 5 mg

69

7.772,16

7.772

909

0000117056957 P ALI MASUDI

01188 17/02/2016 Glikuidon 30 mg

46

55.936,00

76.676

Furosemide 40 mg

23

2.502,40

Allopurinol 300 mg

23

5.873,28

Captopril 50 mg

69

12.364,80

Halaman :

67

No.

No Ka Peserta

910

0000776168515 P MOH.HEKAM

911

Nama

0000116818604 P MOH. SALEH HARYADI

No
Rsp

Tgl Pel

Nama Obat

01189 17/02/2016 Carbamazepine 200 mg

Jml
R/N Obt

Harga
Obat

23

7.212,80

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Sifrol ER 375 mcg

23 211.968,00

01190 17/02/2016 Miniaspi 80 mg

Harga
Diajukan
22.198

226.040

912

0000116995252 P HOSNAWATI

01191 17/02/2016 Glimepiride 4 mg

23

12.659,20

12.659

913

0000116983304 P INDAH MASWIYATI

01192 17/02/2016 Amlodipine 10 mg

23

9.715,20

24.097

Gemfibrozil 300 mg

23

8.508,16

Allopurinol 300 mg

23

5.873,28

23

6.947,84

69

9.936,00

23

12.335,36

Olandoz 10 10 mg

23 329.728,00

01196 17/02/2016 Olandoz 10 10 mg

23 329.728,00

Amlodipine 5 mg

23

5.505,28

Nopres 20 mg

23

12.718,08

Candesartan Cilexetil 8 mg

23

91.264,00

914

0000116932509 P DJUHAIRIJAH

01194 17/02/2016 Glicab 80 mg


Metformin 500 mg

915

916

0000116982573 P FATIMAH FANKIYAH

0000116932904 P DR.HANDOJO,MPH

01195 17/02/2016 Foransi 10 10 mg

16.884

342.063

439.215

917

0001048553109 P DESI ANDRIANI PAUSI

01203 17/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

918

0000774193792 P SALUKI

01204 17/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

919

0000117080144 P DRS. SULAIMAN

01205 17/02/2016 Metformin 500 mg

46

6.624,00

6.624

920

0001128802419 P MOCH.SAHID

01207 17/02/2016 Furosemide 40 mg

23

2.502,40

2.502

921

0001471488311 P BUREYEM

01208 17/02/2016 Micardis 80 mg

23 191.360,00

191.360

922

0000776217712 P DULLA

01210 17/02/2016 Propiltiourasil 100 mg

138

56.348,16

57.855

11

1.506,56

69

28.174,08

46

3.827,20

Propranolol 40 mg
923

0000166178733 P SITI NURUL KOMARIYAH 01217 17/02/2016 Propiltiourasil 100 mg


Propranolol 10 mg

32.001

924

0000117065057 I SRI JUHARLIM

01220 17/02/2016 Gemfibrozil 300 mg

23

8.508,16

8.508

925

0000773742576 P MIDAH

01224 17/02/2016 Captopril 25 mg

69

7.418,88

7.419

Halaman :

68

No.

No Ka Peserta

926

0000049204271 P HATIMAH

Nama

No
Rsp

Tgl Pel

Nama Obat

01240 18/02/2016 Miniaspi 80 mg

Jml
R/N Obt

Harga
Obat

189,44

Isosorbid Dinitrat 5 mg

69

7.772,16

Concor 2,5 mg

23

21.962,24

01241 18/02/2016 Micardis 80 mg

23 191.360,00

191.360

1 142.799,58

142.800
244.155

927

0000119231976 P DR. RIJANTO

928

0000116986509 P SITTI ROKAYYAH NASIR 01247 18/02/2016 Seretide Diskus 250 250 mcg/puff

929

0000116963717 P SAUDI IDRIS

23

9.715,20

Lisinopril 5 mg

23

10.304,00

Lantus Solostar 100 UI/ml

Metformin 500 mg

69

9.936,00

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Lisinopril 5 mg

23

10.304,00

69

5.740,80

23

9.391,36

23

12.659,20

69

9.936,00

517,12

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

23

3.312,00

46

23.846,40

Depakote ER 250 mg

23

82.225,92

Clorilex 100 100 mg

12

76.800,00

930

931

0000116940396 P JAJUK KUSTIRAHAYU

0000775485966 P ARTINI

01248 18/02/2016 Amlodipine 10 mg

01249 18/02/2016 Miniaspi 80 mg

01251 18/02/2016 Propranolol 10 mg


Propiltiourasil 100 mg

932

0000777931683 P ABD.KARIM

01271 18/02/2016 Glimepiride 4 mg


Metformin 500 mg

933

934

0000116909076 I S U R A T M I

0000775591525 P IMKAROLINA

Harga
Diajukan

01272 18/02/2016 Glimepiride 3 mg

01273 18/02/2016 Trifluoperazin 5 mg

29.924

2 214.200,00

24.376

15.132

22.595

12.337

182.872

935

0000117080682 I SITI RISQIATUL JANNAH 01274 18/02/2016 Propranolol 10 mg

46

3.827,20

3.827

936

0000116891177 P SULIMAH JD SAROEDJI 01275 18/02/2016 Captopril 50 mg

69

12.364,80

12.365

937

0000116983798 P LILIS SETYORINI

01297 18/02/2016 Alprazolam 0,5 mg

12

3.287,04

3.287

938

0000117124547 P RUKIYATUN
KUSDWITANTY

01298 18/02/2016 Bisoprolol 5 mg

23

18.988,80

118.615

Isosorbid Dinitrat 5 mg

69

7.772,16

Berotec MDI 100 mcg/puff

91.854,00

23

3.150,08

939

0001894864252 P MUAYYAH

Halaman :

69

01299 18/02/2016 Propranolol 40 mg

19.725

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Thyrozol 5 mg

940

0001476138486 P MUH MASYKUR

942

943

944

0000117005174 P FAHRUDIN RASYIDI,


S.PD

0000775047914 P SUJAI

0000116909954 I RR. SOELAMI WS.

0001293041968 P SITI MAHMUDAH

Harga
Obat

23

16.574,72

12

76.800,00

23

29.675,52

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

01307 18/02/2016 Miniaspi 80 mg

23

4.357,12

Concor 2,5 mg

23

21.962,24

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

01302 18/02/2016 Clorilex 100 100 mg


Risperidon 2 mg

941

Jml
R/N Obt

01305 18/02/2016 Miniaspi 80 mg

01309 18/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

Gliclazide 60 mg

12

84.480,00

Metformin 500 mg

46

6.624,00

01313 18/02/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

1 142.799,58

142.800
26.408

0001048322834 P INDAH LIA

01324 18/02/2016 Bisoprolol 5 mg

23

18.988,80

Captopril 25 mg

69

7.418,88

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

Metformin 500 mg

69

9.936,00

01326 18/02/2016 Miniaspi 80 mg

23

4.357,12

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

Novorapid Flexpen 100 UI/ml

6 645.208,20

Lantus Solostar 100 UI/ml

2 214.200,00

949

0001476568686 P SADIEH

0001048687176 P MIFTAHUL ARIFIN

Halaman :

70

233.904

2 214.200,00

946

948

35.397

N
N

01325 18/02/2016 Miniaspi 80 mg

13.435

6 645.208,20

0000117062605 P ABDUL QADIR DJAELANI 01314 18/02/2016 Seretide Diskus 250 250 mcg/puff

0000116847832 P MOHAMMAD BADRUL

106.476

945

947

Harga
Diajukan

859.408

23.371

1.064.841

9.715,20

01330 18/02/2016 Allopurinol 300 mg

23

5.873,28

Propranolol 10 mg

69

5.740,80

11.614

No.

No Ka Peserta

950

0000199657225 I UMI SULCHAH

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

01331 18/02/2016 Allopurinol 300 mg

23

5.873,28

Metformin 500 mg

69

9.936,00

Harga
Diajukan
15.809

951

0000782181033 P ADNA

01332 18/02/2016 Captopril 50 mg

69

12.364,80

12.365

952

0002033898614 P MISTARI

01337 18/02/2016 Gemfibrozil 300 mg

23

8.508,16

8.508

953

0001431541719 P HOSNIYAH

01342 19/02/2016 Clorilex 100 100 mg

32.000,00

32.000

954

0000116980863 P AFANDI

01348 19/02/2016 Fenofibrate 100 mg

23

31.648,00

31.648

955

0000116984103 S SUDARMO

01360 19/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

956

0000116909998 P MAMNU'AH, A.MA

01364 19/02/2016 Diovan 80 mg

23 114.816,00

114.816

957

0001827829157 P DIAH IMMIYATI

01367 19/02/2016 Captopril 25 mg

69

7.418,88

39.067

Fenofibrate 100 mg

23

31.648,00

01369 19/02/2016 Gemfibrozil 300 mg

23

8.508,16

23

5.873,28

23

9.715,20

23

18.988,80

958

0000116983506 P ISNUR LAILI

Allopurinol 300 mg
959

0000116952052 I SITI AMINATUS


SUHRIJAH

01370 19/02/2016 Amlodipine 10 mg


Bisoprolol 5 mg

960

961

0001306752748 P LATIFAH

0000774896466 P MARINTEN

01371 19/02/2016 Lantus Solostar 100 UI/ml

0001383285857 P RUMSIATI

69

9.936,00

01373 19/02/2016 Amlodipine 10 mg

23

9.715,20

23

18.988,80

46

13.895,68

69

9.936,00

23

11.893,76

23

2.502,40

46

66.828,80

69

5.740,80

01383 20/02/2016 Miniaspi 80 mg

23

4.357,12

Micardis 80 mg

23 191.360,00

3 322.604,10

01374 19/02/2016 Glicab 80 mg


Metformin 500 mg

963

0000773694843 P HASAN

01376 19/02/2016 Glimepiride 3 mg


Furosemide 40 mg

964

0001048374922 P SAMI

01377 19/02/2016 Thyrozol 10 mg


Propranolol 10 mg

965

966

0000116668023 P AHMAD KHOIRI

0000116984687 P MOHAMMAD PANJAR

Halaman :

71

1 107.100,00

Metformin 500 mg

Bisoprolol 5 mg
962

01388 20/02/2016 Novorapid Flexpen 100 UI/ml


Allopurinol 300 mg

Lantus Solostar 100 UI/ml

23

5.873,28

1 107.100,00

14.381

28.704

117.036

28.704

23.832

14.396

72.570

195.717

435.577

No.

No Ka Peserta

967

0000773943884 P ROHMAN SODIK

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

01392 20/02/2016 Vitamin B6 10 mg

16

2.252,80

Phenytoin 100 mg

69

11.746,56

Harga
Diajukan
13.999

968

0001410230518 P MUSLIMAH

01395 20/02/2016 Levopar 125 mg komb

69 132.480,00

132.480

969

0000167005449 1 ARIEF SALDI


WARDIANNUR

01397 20/02/2016 Vitamin B6 10 mg

16

2.252,80

13.999

Phenytoin 100 mg

69

11.746,56

23

39.479,04

Nopres 20 mg

12

6.635,52

Alprazolam 0,5 mg

23

6.300,16

46

13.895,68

Akarbose 100 mg

46

58.291,20

Metformin 500 mg

69

9.936,00

01410 20/02/2016 Metformin 500 mg

23

3.312,00

23

2.472,96

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Metformin 500 mg

69

9.936,00

23 191.360,00

Novorapid Flexpen 100 UI/ml

3 322.604,10

Lantus Solostar 100 UI/ml

1 107.100,00

970

971

972

0001871727805 P MISNATI

0000116930171 I SUDARMI

0000116899446 I SAHRIYAH

01406 20/02/2016 Merlopam 2 mg

01409 20/02/2016 Glicab 80 mg

Captopril 25 mg
973

974

0000116899435 P SAHRI

0000116932116 P DJAMALIYAH

01411 20/02/2016 Amlodipine 10 mg

01412 20/02/2016 Micardis 80 mg

52.415

82.123

5.785

37.315

621.064

975

0000116986329 P SITI HUZAIMAH

01420 20/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

976

0000116934311 P DRS.MOH.KADIR

01421 20/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

977

0000116954076 P MUNI AH JD. ATMAWI

01422 20/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

978

0001862854931 P MUHAMAD HAMID

01423 20/02/2016 Miniaspi 80 mg

23

4.357,12

46.309

Lisinopril 5 mg

23

10.304,00

Fenofibrate 100 mg

23

31.648,00

23

7.212,80

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

21.962,24

979

980

0000777308499 P ABD SAKUR

0000775211984 P ASMONI

Halaman :

72

01424 20/02/2016 Carbamazepine 200 mg

01438 20/02/2016 Concor 2,5 mg

22.198

29.381

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Captopril 25 mg

981

982

0000116908255 P ISHAK

0000117126369 1 DWI CANDRA BAGUS K.

Jml
R/N Obt

Harga
Obat

69

7.418,88

23

11.893,76

Metformin 500 mg

69

9.936,00

01440 20/02/2016 Olandoz 10 10 mg

12 172.032,00

01439 20/02/2016 Glimepiride 3 mg

Clorilex 100 100 mg

1 127.049,58

127.050
24.582

38.400,00

01441 20/02/2016 Seretide Diskus 100 100 mcg/puff

984

0000117516611 I ERNAWATI

01442 20/02/2016 Furosemide 40 mg

23

2.502,40

Amlodipine 10 mg

23

9.715,20

Captopril 50 mg

69

12.364,80

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Berotec MDI 100 mcg/puff

91.854,00

Metformin 500 mg

69

9.936,00

01444 20/02/2016 Trifluoperazin 5 mg

23

11.923,20

Clorilex 100 100 mg

38.400,00

46

66.828,80

69

5.740,80

986

987

0001482889037 P SUGIYONO

0000774820236 P SITTI FATMA

01443 20/02/2016 Amlodipine 10 mg

01445 20/02/2016 Thyrozol 10 mg


Propranolol 10 mg

210.432

0001265705785 P HADIJAH

0000198517342 I IZZATI

21.830

983

985

Harga
Diajukan

123.399

50.323

72.570

988

0000116985047 I SUNARTI

01446 20/02/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

989

0000174063047 I SHOFIAH

01447 20/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

990

0000117099314 2 MASNUN NUR


ARIFANIYAH

01455 20/02/2016 Olandoz 10 10 mg

23 329.728,00

336.028

Alprazolam 0,5 mg

23

6.300,16

01459 22/02/2016 Amlodipine 10 mg

23

9.715,20

Gemfibrozil 300 mg

23

8.508,16

Novorapid Flexpen 100 UI/ml

5 537.673,50

Lantus Solostar 100 UI/ml

4 428.400,00

991

0000149090984 P RIFADI

984.297

992

0000776623059 P JUMAATI

01462 22/02/2016 Thyrozol 10 mg

23

33.414,40

33.414

993

0000773783019 P KHOTIMATUS

01463 22/02/2016 Thyrozol 10 mg

46

66.828,80

70.656

46

3.827,20

23

5.505,28

Propranolol 10 mg
994

0000116950241 P MOH.DAHURI

Halaman :

73

01466 22/02/2016 Amlodipine 5 mg

20.137

No.

995

996

997

No Ka Peserta

Nama

0001048494688 P ERFAN ARIFANDI

0000776116258 P SUTIYEH

0000116851263 I SUHRIYAH

No
Rsp

Tgl Pel

Nama Obat

999

0000207583558 I SRI HARTIYAH

0000116902967 P ACH. BARDI

1000 0000117126382 P CAHYONO MAULADI ,


AMK

1001 0001260878646 P H.MAWARDI

1002 0001321097319 P ABDUL HOLID

23

9.273,60

Digoksin 0,25 mg

23

2.855,68

Furosemide 40 mg

23

2.502,40

01467 22/02/2016 Alprazolam 0,5 mg

23

6.300,16

Olandoz 10 10 mg

23 329.728,00

23

4.357,12

Furosemide 40 mg

12

1.305,60

Lisinopril 5 mg

23

10.304,00

01471 22/02/2016 Miniaspi 80 mg

23

4.357,12

23

5.505,28

23

8.508,16

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Allopurinol 300 mg

23

5.873,28

23

9.715,20

Allopurinol 300 mg

23

5.873,28

Candesartan Cilexetil 8 mg

23

91.264,00

46 164.451,84

Olandoz 10 10 mg

46 659.456,00

01477 22/02/2016 Amlodipine 10 mg

23

9.715,20

Glikuidon 30 mg

23

27.968,00

Furosemide 40 mg

23

2.502,40

Dopamet 250 mg

69

70.656,00

23

9.715,20

69

70.656,00

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

01488 22/02/2016 Miniaspi 80 mg

23

4.357,12

69

7.772,16

01468 22/02/2016 Miniaspi 80 mg

01472 22/02/2016 Gemfibrozil 300 mg

01473 22/02/2016 Amlodipine 10 mg

01476 22/02/2016 Depakote ER 250 mg

01478 22/02/2016 Amlodipine 10 mg


Dopamet 250 mg

1003 0000773891076 P ARIYAH

1004 0001410235659 P SYAIFUL ZAIN

01479 22/02/2016 Amlodipine 10 mg

Isosorbid Dinitrat 5 mg

Halaman :

74

Harga
Obat

Spironolacton 25 mg

Amlodipine 5 mg
998

Jml
R/N Obt

Harga
Diajukan

336.028

15.967

9.862

43.085

106.852

823.908

110.842

80.371

28.704

29.204

No.

No Ka Peserta

Nama

1005 0000117491264 P RUKMINI

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Ramipril 5 mg

23

01489 22/02/2016 Diovan 80 mg

23 114.816,00

23

Amlodipine 10 mg
1006 0000773892494 P KAMARIATUL JANNAH

01490 22/02/2016 Seretide Diskus 250 250 mcg/puff

1007 0000117055866 S NAWAWI

01495 22/02/2016 Miniaspi 80 mg

Amlodipine 10 mg

Harga
Diajukan

17.075,20
124.531

9.715,20

1 142.799,58

142.800

23

4.357,12

113.138

23

9.715,20

Candesartan Cilexetil 8 mg

23

91.264,00

Glimepiride 1 mg

23

7.801,60

1008 0000117081876 P MARIA THERESIA


SETYAWATI
1009 0000774324404 P HASUNAH

01496 22/02/2016 Clopidogrel 75 mg

23 100.096,00

100.096

01497 22/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

1010 0000116886126 P MOCH. IKSAN

01502 22/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

1011 0000116963684 P SATUAH JD SURI

01503 22/02/2016 Micardis 80 mg

23 191.360,00

213.734

Amlodipine 10 mg

23

9.715,20

Glimepiride 4 mg

23

12.659,20

1012 0000169910627 S RUKSIN

01505 22/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1013 0000116949262 I SITI ROCHYATIN

01506 22/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

379.595

1014 0000116886137 I SITI AISJAH

Glimepiride 4 mg

Lantus Solostar 100 UI/ml

Metformin 500 mg

69

9.936,00

23

11.893,76

Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

Fenofibrate 100 mg

23

31.648,00

01507 22/02/2016 Glimepiride 3 mg

23

12.659,20

2 214.200,00

63.193

1015 0001966982927 P HAMAH

01518 22/02/2016 Symbicort 160/4.5mcg

1 148.176,00

148.176

1016 0001317289937 P HAIRIYAH

01519 22/02/2016 Novorapid Flexpen 100 UI/ml

5 537.673,50

678.953

1017 0000116796159 P DHARMA KRISTYANTO

Halaman :

75

Allopurinol 100 mg

Lantus Solostar 100 UI/ml

Fenofibrate 100 mg

23

31.648,00

23

3.238,40

01520 22/02/2016 Vitamin B6 10 mg

23

2.531,84

1 107.100,00

14.985

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Phenytoin 100 mg

Jml
R/N Obt

Harga
Obat

69

11.746,56

23

5.505,28

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

17.075,20

Spironolacton 25 mg

23

9.273,60

Digoksin 0,25 mg

23

2.855,68

Furosemide 40 mg

23

2.502,40

01538 22/02/2016 Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

Akarbose 100 mg

46

58.291,20

23

33.414,40

Propranolol 10 mg

46

3.827,20

01543 22/02/2016 Propranolol 10 mg

69

5.740,80

Thyrozol 5 mg

23

16.574,72

1023 0001048552086 P RAHBINI

01559 22/02/2016 Seretide Diskus 250 250 mcg/puff

1024 0000775334878 P SUBAIDI

01564 22/02/2016 Trifluoperazin 5 mg

1018 0000117021227 P MOHAMAD HARIYADI D

1019 0001410386534 P HARI

1020 0000116987062 P SUKRAH

1021 0000775058253 P BAHRUD

1022 0000775920802 P ROMLAH

01521 22/02/2016 Amlodipine 5 mg

01524 22/02/2016 Ramipril 5 mg

01540 22/02/2016 Thyrozol 10 mg

Harga
Diajukan

20.490

31.707

80.886

37.242

22.316

1 142.799,58

142.800

46

23.846,40

28.086

23

4.239,36

46

13.895,68

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

01576 23/02/2016 Amlodipine 10 mg

23

9.715,20

Glicab 80 mg

46

13.895,68

Furosemide 40 mg

23

2.502,40

Metformin 500 mg

69

9.936,00

01577 23/02/2016 Amlodipine 10 mg

23

9.715,20

Glicab 80 mg

46

13.895,68

Miniaspi 80 mg

23

4.357,12

1028 0000779796494 P K.ALAWI

01580 23/02/2016 Lisinopril 5 mg

23

10.304,00

10.304

1029 0000116906319 P FATIMATUZ ZAHRAH

01586 23/02/2016 Thyrozol 10 mg

46

66.828,80

76.132

Klorpromazin 100 mg
1025 0000117033614 P SITI RAMLAH

1026 0000116939542 P HJ.SITI JASIRAH

1027 0000116935986 P H. MOH. EKSAN HS

Halaman :

76

01575 23/02/2016 Glicab 80 mg

27.968

36.049

27.968

No.

No Ka Peserta

1029 0000116906319 P

Nama
JD.M.NOR

1030 0000116917176 I MAISINTI

No
Rsp

Tgl Pel

Nama Obat

01586 23/02/2016 Thyrozol 10 mg

Jml
R/N Obt

Harga
Obat

46

66.828,80

Captopril 12,5 mg

69

5.475,84

Propranolol 10 mg

46

3.827,20

23

11.893,76

69

9.936,00

01594 23/02/2016 Glimepiride 3 mg


Metformin 500 mg

Harga
Diajukan

76.132

21.830

1031 0000117032681 P NANIK SUGIARTI

01598 23/02/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

215.069

1032 0000117121522 P LIEN CHAJATI

01599 23/02/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

222.488

1033 0000774273238 P SUDARMAN

Captopril 25 mg

69

7.418,88

01608 23/02/2016 Lisinopril 10 mg

23

17.664,00

23

9.715,20

Amlodipine 10 mg

27.379

1034 0000117161572 I HALIMATUS SADIYAH

01609 23/02/2016 Glimepiride 3 mg

23

11.893,76

11.894

1035 0000116931789 P DARSONO

01615 23/02/2016 Miniaspi 80 mg

23

4.357,12

27.718

Amlodipine 10 mg

23

9.715,20

Allopurinol 300 mg

23

5.873,28

Isosorbid Dinitrat 5 mg

69

7.772,16

01616 23/02/2016 Isosorbid Dinitrat 5 mg

69

7.772,16

Allopurinol 300 mg

23

5.873,28

Miniaspi 80 mg

23

4.357,12

Lisinopril 10 mg

23

17.664,00

Metformin 500 mg

69

9.936,00

1036 0000117130037 P HERI WIDIASTUTI

45.603

1037 0001048393337 P AMI

01617 23/02/2016 Diovan 80 mg

23 114.816,00

114.816

1038 0000116987411 P SUTARJO

01618 23/02/2016 Gemfibrozil 300 mg

23

8.508,16

14.381

Allopurinol 300 mg

23

5.873,28

01631 23/02/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

01632 23/02/2016 Glibenklamide 5 mg

46

3.297,28

Fenofibrate 100 mg

23

31.648,00

Lantus Solostar 100 UI/ml

1 107.100,00

1 133.560,00

1039 0000116828943 P ABDULLAH, S.AG

Glimepiride 4 mg
1040 0000117131117 P MOHAMMAD ANSHARI

1041 0000117131229 P TOHARI

01633 23/02/2016 Novomix Flexpen 100 UI/ml


Fenofibrate 100 mg

Halaman :

77

23

31.648,00

22.595

142.045

175.144

No.

No Ka Peserta

Nama

1042 0000117130972 P DIDIK ATRAWI

No
Rsp

Tgl Pel

Nama Obat

Harga
Obat

Metformin 500 mg

69

9.936,00

01634 23/02/2016 Metformin 500 mg

69

9.936,00

Lantus Solostar 100 UI/ml


1043 0000778296137 P NURHAYATI

Jml
R/N Obt

01635 23/02/2016 Amlodipine 10 mg

N
N

Harga
Diajukan

117.036

1 107.100,00
23

9.715,20

124.234

Lantus Solostar 100 UI/ml

Captopril 25 mg

69

7.418,88

23

11.893,76

11.894

1 142.799,58

142.800

1 107.100,00

1044 0000168052882 I HANUN

01636 23/02/2016 Glimepiride 3 mg

1045 0000116782233 P MUHAMMAD SAHERI

01637 23/02/2016 Seretide Diskus 250 250 mcg/puff

1046 0000116907671 P HEDJI, SH

01638 23/02/2016 Captopril 25 mg

69

7.418,88

7.419

1047 0000117180426 S ABD. RAKIP

01639 23/02/2016 Miniaspi 80 mg

23

4.357,12

112.225

Isosorbid Dinitrat 5 mg

69

7.772,16

Clopidogrel 75 mg

23 100.096,00

1 142.799,58

1048 0000117062504 P M RAMLI

1049 0000116984709 P MOHAMMAD RIDA`I

1050 0000117070615 P MAIHASANAH

01642 23/02/2016 Seretide Diskus 250 250 mcg/puff


Lisinopril 10 mg

23

17.664,00

Bisoprolol 5 mg

23

18.988,80

Furosemide 40 mg

23

2.502,40

01643 23/02/2016 Amlodipine 10 mg

23

9.715,20

Miniaspi 80 mg

23

4.357,12

Ramipril 5 mg

23

17.075,20

Captopril 25 mg

69

7.418,88

01644 23/02/2016 Apidra Solostar 100 UI/ml

2 199.495,80

Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

181.955

38.566

226.875

1051 0001126067411 P AHMAD JUFRI SETIAWAN 01645 23/02/2016 Novorapid Flexpen 100 UI/ml
HADI
Lantus Solostar 100 UI/ml

3 322.604,10

1 107.100,00

1052 0000116798556 P ALIMUDIN, SH

23

19.989,76

Glimepiride 4 mg

23

12.659,20

1053 0002034135101 P MOH. ASMONI

01662 23/02/2016 Glimepiride 3 mg

23

11.893,76

11.894

1054 0000116939182 P HJ. SUFIATI

01663 23/02/2016 Glicab 80 mg

23

6.947,84

26.599

Halaman :

78

01661 23/02/2016 Gemfibrozil 600 mg

429.704

32.649

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

1055 0000775630787 P MUSLIHAH

01675 23/02/2016 Metformin 500 mg

69

9.936,00

9.936

1056 0001896921167 P ZUBAIDAH

01676 23/02/2016 Thyrozol 10 mg

23

33.414,40

35.328

23

1.913,60

46

66.828,80

Propranolol 40 mg

34

4.656,64

01697 24/02/2016 Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Candesartan Cilexetil 8 mg

23

91.264,00

23

8.508,16

Allopurinol 300 mg

23

5.873,28

Glibenklamide 5 mg

23

1.648,64

Propranolol 10 mg
1057 0001048637463 P FARIDAH

1058 0000116556761 I RUSMAH

1059 0001454129032 P KURSIYAH

1060 0000116790682 I KUSUMA WARNI


NINGSIH
1061 0000116790693 2 DEWI NOERFADYLAH

01696 24/02/2016 Thyrozol 10 mg

01704 24/02/2016 Gemfibrozil 300 mg

01706 24/02/2016 Seretide Inhaler 50 50 mcg/puff

01707 24/02/2016 Carbamazepine 200 mg

Vitamin B6 10 mg
Phenytoin 100 mg

71.485

119.968

16.030

1 114.240,42

114.240

46

14.425,60

29.411

23

3.238,40

69

11.746,56

23

16.574,72

23

3.150,08

23

1.648,64

Metformin 500 mg

46

6.624,00

01721 24/02/2016 Metformin 500 mg

23

3.312,00

23

12.659,20

46

23.846,40

Olandoz 5 5 mg

23 189.888,00

01723 24/02/2016 Thyrozol 10 mg

23

33.414,40

Propranolol 40 mg

23

3.150,08

1067 0001107471306 P EMY MURDIANINGSIH

01724 24/02/2016 Metformin 500 mg

69

9.936,00

9.936

1068 0000776217712 P DULLA

01728 24/02/2016 Thyrozol 10 mg

46

66.828,80

70.656

1062 0000173770918 2 ANISATUL KAMILAH

01719 24/02/2016 Thyrozol 5 mg


Propranolol 40 mg

1063 0001410103822 P HAMIDAH

1064 0000773654804 P UMMAH

01720 24/02/2016 Glibenklamide 5 mg

Glimepiride 4 mg
1065 0001267593208 P ILHAM WAHYUDI

1066 0000117016165 P LILIK SULAIHA

Halaman :

79

01722 24/02/2016 Trifluoperazin 5 mg

19.725

8.273

15.971

213.734

36.564

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Propranolol 10 mg

1069 0000769397861 P DAI SAIFUL

01731 24/02/2016 Lansoprazole 30 mg


Propranolol 40 mg

1070 0000116813946 P MOH ABUSALIM

01732 24/02/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

1071 0000117026302 P HUZAIMAH

01734 24/02/2016 Glimepiride 4 mg

1073 0000195063219 P A. ZAINI ADAPS

1076 0000116817344 I MISRIYATI

46

3.827,20

23

13.925,12

35

4.793,60

6 645.208,20

2 214.200,00
12.659,20

69

9.936,00

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Micardis 40 mg

23 114.816,00

01739 24/02/2016 Miniaspi 80 mg

23

4.357,12

69

7.772,16

23 191.360,00

23

23 191.360,00

Novorapid Flexpen 100 UI/ml

2 215.069,40

Furosemide 40 mg

Lantus Solostar 100 UI/ml

01737 24/02/2016 Isosorbid Dinitrat 5 mg

01744 24/02/2016 Micardis 80 mg


Glimepiride 2 mg

1075 0000776203514 P MOH.SAHA

23

Isosorbid Dinitrat 5 mg
1074 0000116824509 P NURHASAN

Harga
Obat

Metformin 500 mg
1072 0000117406708 P A FAUZI

Jml
R/N Obt

01746 24/02/2016 Micardis 80 mg

01753 24/02/2016 Miniaspi 80 mg

23

Harga
Diajukan

18.719

859.408

22.595

126.945

12.129

204.196

12.835,84
516.032

2.502,40

1 107.100,00

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Lansoprazole 30 mg

23

13.925,12

26.054

1077 0001295573139 P HATIRAH

01757 24/02/2016 Metformin 500 mg

23

3.312,00

3.312

1078 0000117011946 P RAHAYU SUSILAWATI

01758 24/02/2016 Amlodipine 10 mg

23

9.715,20

606.173

Halaman :

80

Novorapid Flexpen 100 UI/ml

Isosorbid Dinitrat 5 mg

69

7.772,16

Lansoprazole 30 mg

23

13.925,12

Allopurinol 300 mg

23

5.873,28

Lantus Solostar 100 UI/ml

Fenofibrate 100 mg

4 430.138,80

1 107.100,00
23

31.648,00

No.

No Ka Peserta

Nama

1079 0000117094509 P SAUDATUL MAFRUHAH

No
Rsp

Tgl Pel

Nama Obat

01761 25/02/2016 Levopar 125 mg komb

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

69 132.480,00

23 211.968,00

69 132.480,00

23 211.968,00

23

9.273,60

Furosemide 40 mg

23

2.502,40

01764 25/02/2016 Amlodipine 10 mg

23

9.715,20

Fenofibrate 100 mg

23

31.648,00

1083 0000116997671 P R HERRY TRIATMOKO

01770 25/02/2016 Trifluoperazin 5 mg

46

23.846,40

23.846

1084 0000116896713 P H.SLAMET,A.MD

01774 25/02/2016 Merlopam 2 mg

23

39.479,04

39.479

1085 0000117001732 S BITUNG LUGITO

01775 25/02/2016 Merlopam 2 mg

23

39.479,04

45.779

Alprazolam 0,5 mg

23

6.300,16

01779 25/02/2016 Amlodipine 10 mg

23

9.715,20

23

17.664,00

01782 25/02/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

01787 25/02/2016 Amlodipine 10 mg

23

9.715,20

23

13.925,12

23

9.715,20

Captopril 25 mg

46

4.945,92

01800 25/02/2016 Thyrozol 10 mg

23

33.414,40

23

1.913,60

Sifrol ER 375 mcg


1080 0000116965484 P SJAMSUDIN, BA

01762 25/02/2016 Levopar 125 mg komb


Sifrol ER 375 mcg

1081 0001436930831 P MAIMUNAH

1082 0000116944571 P MATSUDI

1086 0000117048767 P MARSUKI

01763 25/02/2016 Spironolacton 25 mg

Lisinopril 10 mg
1087 0001901994625 P YUDI EKO SARI

1088 0000116958813 I DRA.AGUSTINA

Lansoprazole 30 mg
1089 0000116955911 P NY.R.DJUMAINNA

1090 0001885775962 P KHUSNUL KHATIMAH

01788 25/02/2016 Amlodipine 10 mg

Propranolol 10 mg
1091 0000116983719 P KUTSIYAH

1092 0000775310365 P LUBABAH

01805 25/02/2016 Novorapid Flexpen 100 UI/ml


Furosemide 40 mg

Lantus Solostar 100 UI/ml

01806 25/02/2016 Glimepiride 3 mg


Captopril 25 mg

1093 0000116987769 P TUNDJIYAH

01808 25/02/2016 Micardis 80 mg


Allopurinol 300 mg

Halaman :

81

4 430.138,80
23

344.448

344.448

11.776

41.363

27.379

14.985

23.640

14.661

35.328

539.741

2.502,40

1 107.100,00

23

11.893,76

69

7.418,88

23 191.360,00

23

5.873,28

19.313

197.233

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

1094 0000166446213 S MOH. AFFAN

01809 25/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1095 0000117125943 P HARFINI

01810 25/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1096 0000117044616 P MOHAMAD RIFAI

01811 25/02/2016 Glimepiride 4 mg

23

12.659,20

22.595

69

9.936,00

23

8.508,16

23

5.873,28

Metformin 500 mg
1097 0000116722956 P MOH. SUDJONO

01812 25/02/2016 Gemfibrozil 300 mg


Allopurinol 300 mg

1098 0002033898614 P MISTARI

01813 25/02/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

1099 0000117015974 I NADIYATUN

01814 25/02/2016 Alprazolam 1 mg

3 322.604,10

2 214.200,00

23

6.859,52

35

5.017,60

23

4.357,12

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

23 191.360,00

23

8.508,16

69

9.936,00

Glimepiride 2 mg

23

12.835,84

01837 25/02/2016 Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

01838 25/02/2016 Propranolol 10 mg

69

5.740,80

23

16.574,72

23

33.414,40

69

5.740,80

23

21.962,24

23

12.659,20

1107 0001280212547 P MOHAMMAD ZAIFULLAH 01851 26/02/2016 Amlodipine 10 mg


ZIN
Levopar 125 mg komb

23

9.715,20

46

88.320,00

1108 0000116938967 P HJ. HASIRAH

23 191.360,00

23

Amitriptyline 25 mg
1100 0001878185068 P SYAMSUL A.

1101 0001384712313 P ANNI IRMAWATI

01832 25/02/2016 Miniaspi 80 mg

01833 25/02/2016 Micardis 80 mg


Gemfibrozil 300 mg

1102 0000116602841 P MOH SYA`IE

1103 0001470262015 P ROFIDAH

1104 0000166411901 I ROFIQAH

01834 25/02/2016 Metformin 500 mg

Thyrozol 5 mg
1105 0000774580397 P MAHSUNAH

01839 25/02/2016 Thyrozol 10 mg


Propranolol 10 mg

1106 0000776314855 P HELMIYAH SUNAMI

01840 25/02/2016 Concor 2,5 mg


Glimepiride 4 mg

01877 26/02/2016 Micardis 80 mg


Amlodipine 10 mg

Halaman :

82

9.715,20

14.381

536.804

11.877

26.187

199.868

22.772

21.830

22.316

39.155

34.621

98.035

201.075

No.

No Ka Peserta

Nama

1109 0000203899465 I DJUHARIJATI

No
Rsp

Tgl Pel

Nama Obat

01878 26/02/2016 Furosemide 40 mg

Jml
R/N Obt

Harga
Obat

23

23 114.816,00

12

1.305,60

Thyrozol 10 mg

46

66.828,80

Propranolol 10 mg

69

5.740,80

23

9.273,60

23

2.502,40

23

4.357,12

Amlodipine 5 mg

23

5.505,28

Captopril 25 mg

69

7.418,88

1113 0000775485966 P ARTINI

01886 26/02/2016 Thyrozol 10 mg

23

33.414,40

33.414

1114 0000116972807 I HJ. MAHMUDAH


HASANAH
1115 0001827152199 P NURUL KARIMAH

01890 26/02/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

01893 26/02/2016 Lantus Solostar 100 UI/ml

1 107.100,00

107.100

1116 0000116784268 I TRITARTINAH AZIS

01895 26/02/2016 Thyrozol 10 mg

46

66.828,80

68.742

23

1.913,60

23

8.508,16

Amlodipine 10 mg

23

9.715,20

Allopurinol 300 mg

23

5.873,28

Candesartan Cilexetil 8 mg

23

91.264,00

01919 27/02/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

Micardis 40 mg
1110 0000117155373 P JUWAIRIYAH

1111 0000776556483 P MUDIAH

01882 26/02/2016 Furosemide 40 mg

01884 26/02/2016 Spironolacton 25 mg


Furosemide 40 mg

1112 0000117124356 P SRI PARLINA SUGIARTI

01885 26/02/2016 Miniaspi 80 mg

Propranolol 10 mg
1117 0000116942916 I MARNISA

1118 0001410060846 P SRI TARI PUSPA SAFA

01915 27/02/2016 Gemfibrozil 300 mg

2.502,40

Harga
Diajukan
117.318

73.875

11.776

17.281

115.361

14.985

1119 0001048493327 A WARDATUL LAILIYAH

01925 27/02/2016 Thyrozol 10 mg

23

33.414,40

33.414

1120 0001048426042 P ASMO

01931 27/02/2016 Amlodipine 10 mg

23

9.715,20

9.715

1121 0000116823126 P SUHERMANTO

01934 27/02/2016 Thyrozol 10 mg

23

33.414,40

33.414

1122 0001882533464 P NUR MUHAMMAD LATIF

01939 27/02/2016 Miniaspi 80 mg

23

4.357,12

12.129

69

7.772,16

23

16.574,72

Propranolol 10 mg

46

3.827,20

01944 27/02/2016 Propranolol 10 mg

69

5.740,80

Isosorbid Dinitrat 5 mg
1123 0001302820929 P QURROTUL AINI

1124 0000774977242 P JUHAIRIYAH

Halaman :

83

01943 27/02/2016 Thyrozol 5 mg

20.402

22.316

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Thyrozol 5 mg

1125 0000774275927 P SANIRAH

01949 27/02/2016 Glimepiride 4 mg


Metformin 500 mg

1126 0000774629357 P SUAMI

01950 27/02/2016 Miniaspi 80 mg


Isosorbid Dinitrat 5 mg

Jml
R/N Obt

Harga
Obat

23

16.574,72

23

12.659,20

69

9.936,00

23

4.357,12

69

7.772,16

Harga
Diajukan

22.595

12.129

1127 0000775168784 P SAKINA

01951 27/02/2016 Thyrozol 10 mg

23

33.414,40

33.414

1128 0000773652958 P MONARI

01952 27/02/2016 Amlodipine 10 mg

23

9.715,20

31.545

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

1129 0000774937449 P ACHMADI

01953 27/02/2016 Seretide Diskus 250 250 mcg/puff

1130 0001819659925 P MOH.BAHRI

01954 27/02/2016 Depakote ER 250 mg

Clorilex 100 100 mg


Risperidon 2 mg
1131 0000109714476 P INA SUPARSI

1132 0000116928415 P ACHJAK

1133 0001410416177 P FATHOR RAHMAN

1 142.799,58

142.800

23

82.225,92

179.977

38.400,00

46

59.351,04

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

Diovan 80 mg

23 114.816,00

23 408.252,43

Seretide Diskus 250 250 mcg/puff

1 142.799,58

Candesartan Cilexetil 8 mg

23

91.264,00

01967 27/02/2016 Trifluoperazin 5 mg

46

23.846,40

Clorilex 100 100 mg

12

76.800,00

01955 27/02/2016 Amlodipine 10 mg

01965 27/02/2016 Spiriva Refill 18 mcg

132.303

642.316

100.646

1134 0000116988816 P FIRMAN HIDAYAT

01968 27/02/2016 Captopril 25 mg

69

7.418,88

7.419

1135 0000774128632 P KIYEH

01969 27/02/2016 Thyrozol 10 mg

23

33.414,40

35.328

23

1.913,60

Propranolol 10 mg
1136 0000117022206 I SUYATI

01975 27/02/2016 Seretide Diskus 250 250 mcg/puff

1137 0000775080808 P WASILAH

01976 27/02/2016 Propranolol 10 mg

Thyrozol 5 mg
1138 0000202742728 1 ALIFAH RIZKA PUTRI

01981 27/02/2016 Risperidon 2 mg


Trifluoperazin 5 mg

Halaman :

84

1 142.799,58

142.800

46

3.827,20

20.402

23

16.574,72

46

59.351,04

46

23.846,40

83.197

No.

No Ka Peserta

Nama

1139 0001961140768 P SULAIHA

No
Rsp

Tgl Pel

Nama Obat

Harga
Obat

Harga
Diajukan

46

66.828,80

Propranolol 10 mg

69

5.740,80

01982 29/02/2016 Amlodipine 10 mg

23

9.715,20

Captopril 25 mg

69

7.418,88

1141 0001302030674 P SUMI TRISNAWATI

01986 29/02/2016 Thyrozol 10 mg

23

33.414,40

33.414

1142 0001078173944 S AKHMAD EFFENDI

01992 29/02/2016 Spironolacton 25 mg

23

9.273,60

211.173

Isosorbid Dinitrat 5 mg

46

5.181,44

Digoksin 0,25 mg

23

2.855,68

Furosemide 40 mg

23

2.502,40

Clopidogrel 75 mg

23 100.096,00

Candesartan Cilexetil 8 mg

23

91.264,00

23

12.335,36

23 189.888,00

46

33.149,44

46

3.827,20

23

18.988,80

Amlodipine 10 mg

23

9.715,20

Levopar 125 mg komb

46

88.320,00

23

4.357,12

1140 0001893272815 P ROMLI

1143 0000116786935 P IMAM SOPHI

00239 29/02/2016 Thyrozol 10 mg

Jml
R/N Obt

01997 29/02/2016 Foransi 10 10 mg


Olandoz 5 5 mg

1144 0000116959217 I MISRIATUN

01998 29/02/2016 Thyrozol 5 mg


Propranolol 10 mg

1145 0001048464347 P JUANI

1146 0001292062871 P UMMI KULSUM

1147 0000117087085 P PURWANTO

01999 29/02/2016 Bisoprolol 5 mg

02000 29/02/2016 Miniaspi 80 mg


Novorapid Flexpen 100 UI/ml

Furosemide 40 mg

23

2.502,40

Concor 2,5 mg

23

21.962,24

Lantus Solostar 100 UI/ml

2 214.200,00

Micardis 40 mg

23 114.816,00

Fenofibrate 100 mg

23

69 132.480,00

23 211.968,00

02013 29/02/2016 Amlodipine 5 mg

23

5.505,28

Glimepiride 3 mg

23

11.893,76

02012 29/02/2016 Levopar 125 mg komb


Sifrol ER 375 mcg

1148 0000116981188 P AMANIYAH

Halaman :

85

72.570

17.134

202.223

36.977

117.024

1.034.694

6 645.208,20

31.648,00
344.448

27.335

No.

No Ka Peserta

Nama

1149 0000116827852 P MOH ZAINI

1150 0000777977605 P RIFAIE

No
Rsp

Tgl Pel

Nama Obat

69

9.936,00

02014 29/02/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

23

33.414,40

69

5.740,80

23

11.893,76

23

10.304,00

23

11.893,76

69

9.936,00

46

66.828,80

Furosemide 40 mg

23

2.502,40

Propranolol 10 mg

69

5.740,80

23

17.664,00

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

02029 29/02/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

02030 29/02/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

02031 29/02/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

02015 29/02/2016 Thyrozol 10 mg

02016 29/02/2016 Glimepiride 3 mg


Lisinopril 5 mg

1152 0000116910797 P MENA JD.II


SANGNGARAN

02017 29/02/2016 Glimepiride 3 mg


Metformin 500 mg

1153 0000774709975 P MAIDAH

1154 0000774878859 P SANARYAH

1155 0001048661291 P WAHYUDI APRIZAL

1156 0001048465304 P MOH ZUHDI

1157 0000774635387 P MOH ZAINAL AMIN

02027 29/02/2016 Thyrozol 10 mg

02028 29/02/2016 Lisinopril 10 mg

1158 0001138508818 P CAHYO BUDIONO

02032 29/02/2016 Seretide Diskus 250 250 mcg/puff

1159 0000116945807 P MOCH. SADALI

02038 29/02/2016 Miniaspi 80 mg

Isosorbid Dinitrat 5 mg

1160 0000774438399 P SAHERI

Halaman :

86

Harga
Obat

Metformin 500 mg

Propranolol 10 mg
1151 0000116940699 I SUJANI

Jml
R/N Obt

Harga
Diajukan

31.545

39.155

22.198

21.830

75.072

29.440

14.985

14.985

14.985

1 142.799,58

142.800

23

4.357,12

125.032

69

7.772,16

Furosemide 40 mg

23

2.502,40

Lisinopril 5 mg

23

10.304,00

Clopidogrel 75 mg

23 100.096,00

23

02048 29/02/2016 Thyrozol 10 mg

33.414,40

39.155

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Propranolol 10 mg

Jml
R/N Obt

Harga
Obat

69

5.740,80

Harga
Diajukan

1161 0000116977274 P ABOEBAKAR

02049 29/02/2016 Lisinopril 5 mg

23

10.304,00

10.304

1162 0000117055269 P ABUSIRI

02050 29/02/2016 Propranolol 10 mg

69

5.740,80

5.741

1163 000049200186

02054 29/02/2016 Amlodipine 10 mg

23

9.715,20

124.531

23 114.816,00

02055 29/02/2016 Amlodipine 5 mg

23

5.505,28

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

02056 29/02/2016 Glimepiride 4 mg

23

12.659,20

12.659

02066 29/02/2016 Thyrozol 10 mg

23

33.414,40

35.328

Propranolol 10 mg

23

1.913,60

02071 29/02/2016 Vitamin B6 10 mg

16

2.252,80

Phenytoin 100 mg

69

11.746,56

23

17.664,00

23

12.659,20

P BAIDAI

Diovan 80 mg
1164 0000116983394 S ACH. SYAFI'IE

1165 0000116906859 P H.ACHMAD


MUSJAFFAK,BA
1166 0000774338286 P NUR JANNAH

1167 0000768892127 P ABDULLA

1168 0000773726894 P SYAMSIYAH

02072 29/02/2016 Lisinopril 10 mg


Glimepiride 4 mg

1169 0001434124787 P TINIYATUN

02074 29/02/2016 Seretide Diskus 250 250 mcg/puff

1170 0001883702788 P RUMSIYAH

02077 29/02/2016 Amlodipine 10 mg

Lisinopril 10 mg
Bisoprolol 5 mg
1171 0001048572663 P SURIMA

1172 0000117008403 I SITTI AISYAH

27.335

13.999

30.323

1 142.799,58

142.800

23

9.715,20

46.368

23

17.664,00

23

18.988,80

02084 29/02/2016 Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

46

6.624,00

Glimepiride 4 mg

23

12.659,20

02094 29/02/2016 Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

Akarbose 100 mg

46

58.291,20

28.998

90.602

1173 0000116732946 S MOH. MUHRI

02097 29/02/2016 Lisinopril 10 mg

23

17.664,00

17.664

1174 0001268393242 P FATHORRAHMAN

02100 29/02/2016 Micardis 80 mg

23 191.360,00

222.566

23

Amlodipine 10 mg

Halaman :

87

9.715,20

No.

No Ka Peserta

Nama

1175 0001854083586 P BUSANI

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Bisoprolol 5 mg

23

18.988,80

Furosemide 40 mg

23

2.502,40

00006 01/03/2016 Amlodipine 10 mg

23

9.715,20

Novorapid Flexpen 100 UI/ml

Harga
Diajukan

224.785

2 215.069,40
1 142.799,58

142.800

1176 0000117008436 P RISKIYAH

00009 01/03/2016 Seretide Diskus 250 250 mcg/puff

1177 0000100712608 P M FAUZI HOSNI

00013 01/03/2016 Captopril 25 mg

69

7.418,88

7.419

1178 0000117027584 P ABD HALIK

00014 01/03/2016 Amlodipine 5 mg

23

5.505,28

5.505

1179 0001717473104 P NASIDEH

00015 01/03/2016 Amlodipine 10 mg

23

9.715,20

12.218

Furosemide 40 mg

23

2.502,40

00016 01/03/2016 Furosemide 40 mg

23

2.502,40

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

1180 0001439116694 P SUHARINI

203.578

9.715,20

1181 0001473917679 P FATAH HIDAYAT

00017 01/03/2016 Micardis 80 mg

23 191.360,00

191.360

1182 0001830612543 P SUNARWATI

00022 01/03/2016 Glimepiride 4 mg

23

12.659,20

22.595

Metformin 500 mg

69

9.936,00

00031 01/03/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

23

4.357,12

23

5.505,28

1183 0001268418677 P SUHAIRIYAH

Glimepiride 4 mg
1184 0000099996322 P DJUMA I

00032 01/03/2016 Miniaspi 80 mg


Amlodipine 5 mg

22.595

9.862

1185 0001048570378 P BADRIYAH

00033 01/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1186 0000775179573 P JULAEHA

00034 01/03/2016 Candesartan Cilexetil 8 mg

23

91.264,00

91.264

1187 0000774799222 P SANITO

00035 01/03/2016 Miniaspi 80 mg

23

4.357,12

23.905

Furosemide 40 mg

23

2.502,40

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

23

9.715,20

23

4.357,12

23

9.273,60

23

2.502,40

1188 0000774356444 P MAIMUNA

00043 01/03/2016 Amlodipine 10 mg


Miniaspi 80 mg

1189 0000776873889 P HODDIN

00044 01/03/2016 Spironolacton 25 mg


Furosemide 40 mg

Halaman :

88

14.072

19.195

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Captopril 25 mg

1190 0000776682628 P MARSINI

00045 01/03/2016 Furosemide 40 mg


Spironolacton 25 mg

1191 0000116945032 P MISRIANI

00046 01/03/2016 Thyrozol 5 mg


Propranolol 10 mg

1192 0000779286407 P SAPRAWI

00048 01/03/2016 Micardis 80 mg


Furosemide 40 mg

1193 0000167005359 I NURHAYATI

00063 01/03/2016 Miniaspi 80 mg


Lisinopril 10 mg

1194 0000116909818 I MUGHAIRAH

00074 01/03/2016 Metformin 500 mg


Glimepiride 4 mg

1195 0001432117348 P SALANI

00077 01/03/2016 Glikuidon 30 mg


Lantus Solostar 100 UI/ml

1196 0001969610286 P SALAMI

1197 0000098237305 I SUKTIYAH ROKAYYAH

69

7.418,88

12

1.305,60

23

9.273,60

23

16.574,72

46

3.827,20

23 191.360,00

23

2.502,40

23

4.357,12

23

17.664,00

69

9.936,00

23

12.659,20

23

27.968,00

1 107.100,00

23 161.920,00

Micardis 80 mg

23 191.360,00

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

69

9.936,00

23 161.920,00

23

31.648,00

23

2.502,40

23

10.304,00

23

2.855,68

Lisinopril 5 mg

23

10.304,00

Amlodipine 5 mg

23

5.505,28

00078 01/03/2016 Gliclazide 60 mg

00084 01/03/2016 Gliclazide 60 mg

00085 01/03/2016 Furosemide 40 mg


Lisinopril 5 mg

1199 0001428098512 P ABD WAHED

Harga
Obat

Fenofibrate 100 mg
1198 0000172885432 2 SHELY FAIQOTUR
RAUDAH

Jml
R/N Obt

00088 01/03/2016 Digoksin 0,25 mg

Harga
Diajukan

10.579

20.402

193.862

22.021

22.595

135.068

371.724

193.568

12.806

18.665

1200 0000116986961 P SUHAMIYATI

00098 01/03/2016 Diovan 80 mg

23 114.816,00

114.816

1201 0001328705921 P SUMROTI

00101 01/03/2016 Amlodipine 10 mg

23

9.715,20

27.379

23

17.664,00

Lisinopril 10 mg
1202 0000195322397 I MARIYA

00106 01/03/2016 Glimepiride 1 mg

23

7.801,60

7.802

1203 0000117397089 I UMIYATI

00107 01/03/2016 Glimepiride 3 mg

23

11.893,76

22.198

Halaman :

89

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Lisinopril 5 mg

1204 0001324008382 P ZURIYAH

Jml
R/N Obt

Harga
Obat

23

23 161.920,00

Akarbose 100 mg

46

58.291,20

Metformin 500 mg

69

9.936,00

00109 01/03/2016 Gliclazide 60 mg

1205 0001429719377 P SRI WAHYUNINGSIH

00123 02/03/2016 Seretide Diskus 250 250 mcg/puff

1206 0001895639973 P SUBAGIO

00128 02/03/2016 Miniaspi 80 mg

1207 0000776109159 P HAKIMAH

00129 02/03/2016 Seretide Diskus 100 100 mcg/puff

1208 0001048624018 P ZAINULLAH

00133 02/03/2016 Thyrozol 10 mg

1209 0000776958581 P SAMAWI

00136 02/03/2016 Bisoprolol 5 mg

Harga
Diajukan

10.304,00
230.147

1 142.799,58

142.800

4.357,12

4.357

1 127.049,58

127.050

23

33.414,40

33.414

23

18.988,80

26.059

Furosemide 40 mg

11

1.196,80

Allopurinol 300 mg

23

5.873,28

23

1210 0000117014984 I SITI RAHMAH

00143 02/03/2016 Bisoprolol 5 mg

23

18.988,80

18.989

1211 0001451727753 P FALALAH

00148 02/03/2016 Thyrozol 5 mg

12

8.647,68

8.648

1212 0000117090044 I ERMA MEGAWATI

00149 02/03/2016 Thyrozol 10 mg

46

66.828,80

68.742

23

1.913,60

23 209.024,00

23 200.192,00

00156 02/03/2016 Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

1215 0000777848354 P SATONA

00159 02/03/2016 Captopril 50 mg

69

12.364,80

12.365

1216 0001176348464 P IMROATUS SHOLIHAH

00160 02/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1217 0000116981368 P ASMUNI

00166 02/03/2016 Alprazolam 1 mg

23

6.859,52

6.860

1218 0000774010348 P NADIRAH

00167 02/03/2016 Metformin 500 mg

69

9.936,00

17.355

69

7.418,88

23 191.360,00

Glicab 80 mg

46

13.895,68

Metformin 500 mg

69

9.936,00

00174 02/03/2016 Allopurinol 300 mg

23

5.873,28

23

7.801,60

Propranolol 10 mg
1213 0000116621695 P SURIJANTO

00155 02/03/2016 Avodart 0,5 mg


Harnal Ocas 0,4 mg

1214 0000117607498 I LILIK SUHARTATIK

Captopril 25 mg
1219 0000116702302 P MUJIYEM

1220 0000116740348 P ABD SYAKUR

00171 02/03/2016 Micardis 80 mg

Glimepiride 1 mg

Halaman :

90

409.216

23.346

215.192

133.466

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

Micardis 40 mg

23 114.816,00

Simvastatin 10 mg

23

4.975,36

23

4.357,12

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

46

45.926,40

Glicab 80 mg

46

13.895,68

Amlodipine 10 mg

23

9.715,20

Fenofibrate 100 mg

23

31.648,00

Micardis 40 mg

23 114.816,00

46

Micardis 40 mg

23 114.816,00

1224 0001048426042 P ASMO

00185 02/03/2016 Micardis 40 mg

23 114.816,00

114.816

1225 0001410196138 P KHOTIMAH

00186 02/03/2016 Thyrozol 10 mg

46

66.828,80

69.979

23

3.150,08

1221 0001298658543 P SUMNA

1222 0000163394548 P NAFSHATUN

1223 0001048724572 P DIWI

00176 02/03/2016 Miniaspi 80 mg

00177 02/03/2016 Akarbose 50 mg

00181 02/03/2016 Glimepiride 3 mg

Propranolol 40 mg
1226 0000116964099 P SITI ASIYAH

00187 02/03/2016 Seretide Diskus 100 100 mcg/puff

1227 0000117417521 I SITI NURHASANAH

00192 02/03/2016 Glicab 80 mg

Amlodipine 10 mg

1228 0000117025841 P FATHOR ARIFIN

1229 0001811575416 P M.ATMO

1231 0001805942654 P HARIYANTO

91

138.604

127.050

46

13.895,68

30.235

23

9.715,20

Metformin 500 mg

46

6.624,00

00193 02/03/2016 Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

Candesartan Cilexetil 16 mg

23 144.256,00

4 430.138,80

2 214.200,00

00197 02/03/2016 Novorapid Flexpen 100 UI/ml

00199 02/03/2016 Lisinopril 5 mg

23

10.304,00

Apidra Solostar 100 UI/ml

3 299.243,70

Lantus Solostar 100 UI/ml

3 321.300,00

00215 03/03/2016 Trifluoperazin 5 mg


Risperidon 2 mg

Halaman :

216.001

1 127.049,58

Lantus Solostar 100 UI/ml


1230 0000117080065 P BUSTAMI

23.787,52

26.952

46

23.846,40

46

59.351,04

156.474

644.339

630.848

91.676

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Klorpromazin 100 mg

1232 0001133529107 P EKA SUSAN PRIANTO

1233 0001048512159 P ABD.GAFUR

1234 0001855961673 P INSUL ARIF

Jml
R/N Obt
N

46

8.478,72

46

59.351,04

Depakote ER 250 mg

23

82.225,92

Clorilex 100 100 mg

38.400,00

00221 03/03/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

12

76.800,00

46

59.351,04

00217 03/03/2016 Risperidon 2 mg

00229 03/03/2016 Clorilex 100 100 mg


Risperidon 2 mg

1235 0000117042298 P SRI HARTATI NY

00230 03/03/2016 Novorapid Flexpen 100 UI/ml

1236 0000166164917 P ANDYKA BUDIHARTO

00235 03/03/2016 Clorilex 100 100 mg

Alprazolam 0,5 mg
Risperidon 2 mg
1237 0000117110586 P MUYANTI

Harga
Obat

Harga
Diajukan

179.977

14.985

136.151

2 215.069,40

215.069

12

76.800,00

142.451

23

6.300,16

46

59.351,04

69

7.772,16

Amlodipine 10 mg

23

9.715,20

Miniaspi 80 mg

23

4.357,12

Glimepiride 4 mg

23

12.659,20

00236 03/03/2016 Isosorbid Dinitrat 5 mg

34.504

1238 0000774077769 P SLAMA

00237 03/03/2016 Stalevo 325 mg komb

46 524.032,00

524.032

1239 0000775584922 P HOLILATULHOSNA

00254 03/03/2016 Olandoz 10 10 mg

23 329.728,00

333.202

46

3.473,92

46

14.425,60

23 329.728,00

23

8.508,16

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

23

8.508,16

69

7.418,88

Haloperidol 0,5 mg
1240 0001295679982 P HAIKAL BARIO

00256 03/03/2016 Carbamazepine 200 mg


Olandoz 10 10 mg

1241 0000117142751 P MOCHAMAD RUSLI

1242 0000117090797 P JUMRAWI

00267 03/03/2016 Gemfibrozil 300 mg

00269 03/03/2016 Gemfibrozil 300 mg


Captopril 25 mg

344.154

31.103

15.927

1243 0000775354072 P RODIYAH

00273 03/03/2016 Micardis 40 mg

23 114.816,00

114.816

1244 0000776107203 P SRIWAHYUNI

00282 03/03/2016 Propiltiourasil 100 mg

23

9.391,36

13.219

46

3.827,20

Propranolol 10 mg

Halaman :

92

No.

No Ka Peserta

Nama

1245 0001410239542 P SANUKI

No
Rsp

Tgl Pel

Nama Obat

00283 03/03/2016 Miniaspi 80 mg

Jml
R/N Obt

Harga
Obat

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Kalipar 300 mg

23

20.608,00

Harga
Diajukan
35.240

1246 0000117065823 P ANNY ASTUTIK

00292 03/03/2016 Glicab 80 mg

46

13.895,68

13.896

1247 0000117098627 P SRI SUHARTINI

00294 03/03/2016 Glimepiride 3 mg

23

11.893,76

15.206

Metformin 500 mg

23

3.312,00

00295 03/03/2016 Allopurinol 300 mg

23

5.873,28

Metformin 500 mg

69

9.936,00

23

11.893,76

23

4.975,36

1248 0001266542469 P HAMIMAH

1249 0001048518292 P TITIK WAHYUNI

00301 03/03/2016 Glimepiride 3 mg


Simvastatin 10 mg

15.809

16.869

1250 0001410298525 P NURUL HASANAH

00302 03/03/2016 Micardis 80 mg

23 191.360,00

191.360

1251 0000116600488 P HAIRIYAH

00307 03/03/2016 Miniaspi 80 mg

23

4.357,12

12.129

69

7.772,16

Isosorbid Dinitrat 5 mg
1252 0001435164614 P ABD.WAHID SALIM

00310 04/03/2016 Amlodipine 5 mg

23

5.505,28

5.505

1253 0000098253459 P SUATUN

00312 04/03/2016 Gliclazide 60 mg

23 161.920,00

192.420

Amlodipine 10 mg

23

9.715,20

Allopurinol 300 mg

23

5.873,28

Simvastatin 10 mg

23

4.975,36

Metformin 500 mg

69

9.936,00

00325 04/03/2016 Vitamin B6 10 mg

16

2.252,80

Phenytoin 100 mg

69

11.746,56

00335 04/03/2016 Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Clopidogrel 75 mg

23 100.096,00

Isosorbid Dinitrat 5 mg

69

7.772,16

23

2.855,68

23

2.502,40

1254 0000775003386 P MAMLUAH

1255 0001868602522 P MUHDAR ABDULLAH

1256 0001853560517 P SRININGSIH

00349 04/03/2016 Digoksin 0,25 mg


Furosemide 40 mg

1257 0000117130983 P HAIRUL SALEH

Halaman :

93

00350 04/03/2016 Lantus Solostar 100 UI/ml

2 214.200,00

13.999

131.214

5.358

295.086

No.

No Ka Peserta

Nama

1258 0001443194379 P TIHANA

1259 0001326845114 P MUHARROM

1260 0001309758546 P LUKMAN HAKIM

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Akarbose 100 mg

46

58.291,20

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

23

4.357,12

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

46

5.004,80

23

26.496,00

Propranolol 40 mg

35

4.793,60

00358 04/03/2016 Vitamin B6 10 mg

23

3.238,40

Carbamazepine 200 mg

23

7.212,80

Phenytoin 100 mg

69

11.746,56

00353 04/03/2016 Miniaspi 80 mg

00354 04/03/2016 Spironolacton 100 mg

Harga
Diajukan

26.408

31.290

22.198

1261 0001048326377 P HOZAIMAH

00367 05/03/2016 Micardis 80 mg

23 191.360,00

191.360

1262 0000117079086 P MOH. SAYUDI

00370 05/03/2016 Miniaspi 80 mg

23

4.357,12

14.072

23

9.715,20

69

21.638,40

16

2.252,80

Amlodipine 10 mg
1263 0001048545922 P FERI ANGGA RIAWAN

00374 05/03/2016 Carbamazepine 200 mg


Vitamin B6 10 mg

23.891

1264 0000116784066 P ABD. ADHIM

00384 05/03/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

1265 0000116903046 P ACH.MUTTAQI, BA

00385 05/03/2016 Metformin 500 mg

69

9.936,00

20.394

19

10.457,60

69

11.746,56

11.747

Glimepiride 4 mg
1266 0000199058793 S MOHAMMAD ALI MAKKI

00386 05/03/2016 Phenytoin 100 mg

1267 0000173012872 P DWI PUJI PERTIWI

00388 05/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1268 0000198713226 1 IRADATUL ILAHIYAH

00389 05/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1269 0000198713305 2 YUSRIL IZZAT ZARDARI

00390 05/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1270 0001390264694 P MARYANI

00394 05/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1271 0000776047612 P RIZA UMAMI

00395 05/03/2016 Carbamazepine 200 mg

46

14.425,60

17.664

23

3.238,40

23 200.192,00

23 209.024,00

Vitamin B6 10 mg
1272 0000116928696 P ACHMAD HAMBALI

00397 05/03/2016 Harnal Ocas 0,4 mg


Avodart 0,5 mg

Halaman :

94

409.216

No.

No Ka Peserta

Nama

1273 0001295679982 P HAIKAL BARIO

No
Rsp

Tgl Pel

Nama Obat

00401 05/03/2016 Diazepam 2 mg


Risperidon 1 mg

1274 0000100054135 P URIP BUDI SANTOSO

00403 05/03/2016 Amlodipine 10 mg

Harga
Obat

58

3.340,80

R.01 11,5

17.664,00

23

9.715,20

12

8.908,80

00404 05/03/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

Ramipril 5 mg
1275 0001048544109 P NUR AZIZEH

Jml
R/N Obt

Harga
Diajukan
21.005

18.624

14.985

1276 0000773996837 P SUNARYA

00405 05/03/2016 Amlodipine 5 mg

23

5.505,28

5.505

1277 0000116906376 I SITI FATHAH

00406 05/03/2016 Glimepiride 3 mg

23

11.893,76

89.836

Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

Akarbose 100 mg

46

58.291,20

69

7.772,16

Concor 2,5 mg

23

21.962,24

Miniaspi 80 mg

23

4.357,12

Captopril 25 mg

69

7.418,88

Metformin 500 mg

69

9.936,00

00416 05/03/2016 Amitriptyline 25 mg

12

1.720,32

Haloperidol 0,5 mg

46

3.473,92

Alprazolam 0,5 mg

23

6.300,16

46

23.846,40

23

4.239,36

23

18.988,80

Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

23

4.357,12

23

2.502,40

00429 05/03/2016 Amlodipine 5 mg

23

5.505,28

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

46

6.624,00

23

5.505,28

1278 0000117282745 P DJUMAATIYAH JD SAIDI

1279 0000774841061 P HALIMA

1280 0001787915316 P SUPARLAN

00407 05/03/2016 Isosorbid Dinitrat 5 mg

00417 05/03/2016 Trifluoperazin 5 mg


Klorpromazin 100 mg

1281 0000116984968 P MUNIRY

1282 0000777773812 P MATSAHA

00422 05/03/2016 Bisoprolol 5 mg

00424 05/03/2016 Miniaspi 80 mg


Furosemide 40 mg

1283 0000173117665 I RISKIATIN

1284 0000116848844 P MIFTAHOL ARIFIN, SH,

Halaman :

95

00432 05/03/2016 Amlodipine 5 mg

51.446

11.494

28.086

40.598

6.860

24.023

327.675

No.

No Ka Peserta

1284 0000116848844 P

Nama
MM

1285 0000203023361 I SANIMAH

No
Rsp

Tgl Pel

Nama Obat

00432 05/03/2016 Amlodipine 5 mg

Jml
R/N Obt
N

23

Harga
Obat

5.505,28

Novorapid Flexpen 100 UI/ml

2 215.069,40

Lantus Solostar 100 UI/ml

1 107.100,00

00440 07/03/2016 Lisinopril 5 mg

Harga
Diajukan

327.675

23

10.304,00

23

12.835,84

00448 07/03/2016 Vitamin B6 10 mg

16

2.252,80

Phenytoin 100 mg

69

11.746,56

00449 07/03/2016 Amlodipine 10 mg

23

9.715,20

23

3.297,28

23 191.360,00

Amlodipine 10 mg

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

11

1.196,80

1289 0000116981199 P AMINA

00463 07/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1290 0001379620708 P SILVANA TANI

00478 07/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1291 0001297237724 P MOH.ZAINI IHKSAN

00479 07/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1292 0000774233166 P ABDUS SYUKUR

00482 07/03/2016 Spironolacton 25 mg

23

9.273,60

11.776

23

2.502,40

23

11.893,76

69

7.418,88

Glimepiride 2 mg
1286 0000775067016 P LIPAH

1287 0000117022206 I SUYATI

Amitriptyline 25 mg
1288 0000116946145 P MOELJADI

00459 07/03/2016 Micardis 80 mg

Furosemide 40 mg
1293 0001960351187 P RUSLAN MULYADI

00483 07/03/2016 Glimepiride 3 mg


Captopril 25 mg

23.140

13.999

13.012

210.044

19.313

1294 0000775878186 P MOH RIFAI

00484 07/03/2016 Lisinopril 5 mg

23

10.304,00

10.304

1295 0000202346032 P SAKDIJAH

00485 07/03/2016 Olandoz 10 10 mg

23 329.728,00

376.067

Merlopam 2 mg

23

39.479,04

Alprazolam 1 mg

23

6.859,52

00486 07/03/2016 Alprazolam 1 mg

23

6.859,52

Olandoz 10 10 mg

23 329.728,00

Risperidon 2 mg

23

29.675,52

12

76.800,00

23

4.239,36

23

7.801,60

1296 0000117071087 P RUDY SETIAWAN

1297 0000116673221 P SITI KIPIYAH

00487 07/03/2016 Clorilex 100 100 mg


Klorpromazin 100 mg

1298 0000116935942 P H. MOH. ALWI

Halaman :

96

00488 07/03/2016 Glimepiride 1 mg

366.263

81.039

7.802

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

1299 0000780212463 P ACH.SAUKI

00490 07/03/2016 Top Up Hemofilia RS B Reg I NULL

1300 0000117231309 P WIDJIATI

00495 07/03/2016 Micardis 80 mg

1301 0000775204042 P NULRUL IMAM

Harga
Obat

Harga
Diajukan
7.914.200

1 7.914.200,0
0
23 191.360,00

00501 07/03/2016 Furosemide 40 mg

23

2.502,40

2.502

1302 0000116730382 I NURUL FATIMAH

00502 07/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1303 0001410151026 P HASUNAH

00503 07/03/2016 Isosorbid Dinitrat 5 mg

69

7.772,16

132.303

Miniaspi 80 mg

23

4.357,12

Captopril 25 mg

69

7.418,88

Clopidogrel 75 mg

23 100.096,00

Glimepiride 4 mg

23

12.659,20

00504 07/03/2016 Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Furosemide 40 mg

23

2.502,40

1304 0000775253957 P ABD.ROSID

1305 0000116958341 P R.ACH.MASJKUR KAMIL

00516 07/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

191.360

25.848

191.390

Digoksin 0,25 mg

23

2.855,68

Furosemide 40 mg

23

2.502,40

Metformin 500 mg

69

9.936,00

Glibenklamide 5 mg

23

1.648,64

Fenofibrate 100 mg

23

31.648,00

23

2.502,40

Isosorbid Dinitrat 5 mg

69

7.772,16

Amlodipine 10 mg

23

9.715,20

Miniaspi 80 mg

23

4.357,12

00519 07/03/2016 Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Diovan 80 mg

23 114.816,00

1308 0000117000494 P SYAFIUDIN

00520 07/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1309 0000116985284 I SAMSITI

00522 07/03/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

322.169

1 107.100,00

1306 0001082445546 P SRIYATI

1307 0000116830552 P DRS. SANUM MA'MUN,


M.PD.I

00518 07/03/2016 Furosemide 40 mg

Lantus Solostar 100 UI/ml


1310 0000777255287 P SAUMI

Halaman :

97

00532 07/03/2016 Lisinopril 10 mg

23

17.664,00

24.347

128.888

25.466

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Glimepiride 1 mg

Jml
R/N Obt
N

1311 0000116986342 P SITI NURHAYATI

00536 07/03/2016 Seretide Diskus 100 100 mcg/puff

1312 0000117060039 P NUR AINI

00538 07/03/2016 Lisinopril 10 mg

1313 0000116865538 I MUNIRAH

00541 07/03/2016 Amlodipine 10 mg

1314 0000117021082 P ABDUL MAHWAR

1315 0000774818278 P SUBUYAH

1316 0001318125262 P NURUL ANISYAH

23

Harga
Obat

Harga
Diajukan

7.801,60

1 127.049,58

127.050

23

17.664,00

17.664

23

9.715,20

21.521

Spironolacton 25 mg

23

9.273,60

Allopurinol 100 mg

23

2.531,84

00542 07/03/2016 Bisoprolol 5 mg

23

18.988,80

Miniaspi 80 mg

23

4.357,12

Lisinopril 5 mg

23

10.304,00

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

23

12.835,84

Captopril 25 mg

69

7.418,88

00566 08/03/2016 Thyrozol 10 mg

23

33.414,40

23

1.913,60

00546 07/03/2016 Glimepiride 2 mg

Propranolol 10 mg

53.198

20.255

35.328

1317 0000774718929 P PAR'I

00582 08/03/2016 Lisinopril 10 mg

23

17.664,00

17.664

1318 0000770165875 P SAFI UDDIN

00588 08/03/2016 Vitamin B6 10 mg

23

3.238,40

14.985

Phenytoin 100 mg

69

11.746,56

00590 08/03/2016 Micardis 80 mg

23 191.360,00

Miniaspi 80 mg

23

Lantus Solostar 100 UI/ml

Furosemide 40 mg

23

2.502,40

23

5.505,28

Lisinopril 10 mg

23

17.664,00

00599 08/03/2016 Micardis 80 mg

23 191.360,00

23

4.975,36

00600 08/03/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

1319 0000099722092 P KASMAN

1320 0000775427951 P ROFIK

1321 0000116981864 P DJATIM

00593 08/03/2016 Amlodipine 5 mg

Simvastatin 10 mg
1322 0001801424766 P NOVA RISKIYAH

Halaman :

98

305.320

4.357,12

1 107.100,00

23.169

196.335

14.985

No.

No Ka Peserta

Nama

1323 0000775787883 P ABD.AZIZ

No
Rsp

Tgl Pel

Nama Obat

00601 08/03/2016 Amlodipine 10 mg

Diovan 80 mg

23 114.816,00

00612 08/03/2016 Amlodipine 5 mg

69

9.936,00

46

13.895,68

Metformin 500 mg

69

9.936,00

00614 08/03/2016 Furosemide 40 mg

23

2.502,40

69

7.418,88

00615 08/03/2016 Akarbose 100 mg

46

58.291,20

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

23 191.360,00

23

11.893,76

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Furosemide 40 mg

12

1.305,60

23

4.357,12

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

69

7.772,16

Furosemide 40 mg

23

2.502,40

Lisinopril 5 mg

23

10.304,00

Miniaspi 80 mg

23

4.357,12

Glimepiride 3 mg

1331 0000779511464 P SUGIANTO

1332 0001339414413 P ATNA

1333 0000116875631 P MOH.NAJIB

00624 08/03/2016 Spironolacton 25 mg

00625 08/03/2016 Miniaspi 80 mg

00627 08/03/2016 Isosorbid Dinitrat 5 mg

00633 08/03/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

1334 0000114937323 P ACHMAD SURJANTO

Halaman :

99

15.441

00616 08/03/2016 Micardis 80 mg

00652 08/03/2016 Miniaspi 80 mg

3 322.604,10

1 107.100,00

23

267.331

5.873

5.505,28

00613 08/03/2016 Glicab 80 mg

Harga
Diajukan

5.873,28

23

Captopril 25 mg

1330 0001834273956 P ABD.JANNANI

R.01 34,5
N

Metformin 500 mg

1329 0000116935661 P H. ABDUL MUGID

9.715,20

1 142.799,58

1325 0000114817127 I SUPATYA

1328 0000117050062 P MOH SJAIFUL EFENDI

23

00602 08/03/2016 Phenytoin 100 mg

1327 0000116998615 P MOCH NAWAWI

Harga
Obat

Seretide Diskus 250 250 mcg/puff

1324 0000775783934 P MAE

1326 0000172847351 I TAMLIHA

Jml
R/N Obt

4.357,12

23.832

9.921

80.886

203.254

22.708

16.133

24.936

429.704

31.752

No.

No Ka Peserta

Nama

1335 0000769754834 P HADIYAH

No
Rsp

Tgl Pel

Nama Obat

Harga
Obat

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

12

9.907,20

Isosorbid Dinitrat 5 mg

69

7.772,16

23

17.664,00

69

9.936,00

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Gemfibrozil 300 mg

23

8.508,16

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

00653 08/03/2016 Lisinopril 10 mg


Metformin 500 mg

1336 0001127760142 P SYAIFUL RAHMAN

Jml
R/N Obt

00654 08/03/2016 Miniaspi 80 mg

Harga
Diajukan

27.600

45.176

1337 0000166411901 I ROFIQAH

00655 08/03/2016 Seretide Diskus 250 250 mcg/puff

1338 0000116973742 P SITI DJUHRIYAH

00656 08/03/2016 Amlodipine 10 mg

23

Gliclazide 60 mg

23 161.920,00

Micardis 80 mg

23 191.360,00

00657 08/03/2016 Thyrozol 10 mg

46

66.828,80

Propranolol 10 mg

69

5.740,80

00672 08/03/2016 Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Glimepiride 2 mg

46

25.671,68

Fenofibrate 100 mg

23

31.648,00
7.914.200

68.742

1339 0000117161572 I HALIMATUS SADIYAH

1340 0000166444806 I SUSMAWARI NINGSIH

1 142.799,58

142.800

9.715,20

362.995

1341 0001270168301 P ACH.KUSWANDI

02221 08/03/2016 Top Up Hemofilia RS B Reg I NULL

1342 0000775311671 P SUSMIYATI

00683 10/03/2016 Glimepiride 4 mg

1 7.914.200,0
0
23
12.659,20

1343 0000116821405 I SUDARSIH

00684 10/03/2016 Thyrozol 10 mg

46

66.828,80

23

1.913,60

23

21.962,24

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

12

1.305,60

00699 10/03/2016 Vitamin B6 10 mg

16

2.252,80

Phenytoin 100 mg

69

11.746,56

Propranolol 10 mg
1344 0000776679142 P MARDIYANA

1345 0001385196142 P TEDI RIAN HANDIKA

Halaman :

100

00693 10/03/2016 Concor 2,5 mg

72.570

84.699

12.659

32.541

13.999

No.

No Ka Peserta

Nama

1346 0001410409552 P INDAH LESTARI K

1347 0000117342358 P R.AJ.AFIYAH


JD.DJAMALUDIN

1348 0000117082326 P SUMARWAN

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

00706 10/03/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

69

7.772,16

Diovan 80 mg

23 114.816,00

Miniaspi 80 mg

23

4.357,12

Amlodipine 5 mg

23

5.505,28

Bisoprolol 5 mg

23

18.988,80

Allopurinol 100 mg

23

2.531,84

00721 10/03/2016 Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Isosorbid Dinitrat 5 mg

69

7.772,16

Captopril 25 mg

69

7.418,88

00719 10/03/2016 Isosorbid Dinitrat 5 mg

1349 0000159890894 P RUMMINI

00722 10/03/2016 Lantus Solostar 100 UI/ml

1350 0000116782942 P SLAMET SUPRIYADI

00723 10/03/2016 Furosemide 40 mg

23

Diovan 80 mg

23 114.816,00

Dopamet 250 mg

46

47.104,00

Harga
Diajukan
14.985

153.971

38.537

1 107.100,00

107.100

2.502,40

164.422

1351 0000117081606 I SITI HAMIDAH

00724 10/03/2016 Gemfibrozil 300 mg

23

8.508,16

8.508

1352 0000774736997 P SI'A

00725 10/03/2016 Concor 2,5 mg

23

21.962,24

39.317

Captopril 25 mg

69

7.418,88

Metformin 500 mg

69

9.936,00

1353 0001410165652 P KIPTIYAH

00726 10/03/2016 Glimepiride 3 mg

23

11.893,76

11.894

1354 0000202403452 2 MOH RIFKI NUR WAHID

00750 10/03/2016 Carbamazepine 200 mg

23

7.212,80

69.802

Risperidon 2 mg

R.01

46

59.351,04

Vitamin B6 10 mg

R.01

23

3.238,40

12

1.305,60

46

3.650,56

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Captopril 25 mg

69

7.418,88

1355 0000774626253 P MASSORI

00755 10/03/2016 Furosemide 40 mg


Captopril 12,5 mg

1356 0001048397398 P HOLLA

Halaman :

101

00758 10/03/2016 Miniaspi 80 mg

4.956

19.548

No.

No Ka Peserta

Nama

1357 0000116798905 P HENDRO SANTOSO

No
Rsp

Tgl Pel

Nama Obat

00759 10/03/2016 Miniaspi 80 mg

Jml
R/N Obt

Harga
Obat

23

4.357,12

Amlodipine 5 mg

23

5.505,28

Concor 2,5 mg

23

21.962,24

Candesartan Cilexetil 8 mg

23

91.264,00

Harga
Diajukan
123.089

1358 0001269442089 P INTAN TRI LESTARI

00762 10/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1359 0000116714171 P SRI WAHYUNI

00763 10/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1360 0000081456838 P SOEHARTI

00764 10/03/2016 Micardis 80 mg

23 191.360,00

199.132

69

7.772,16

Isosorbid Dinitrat 5 mg
1361 0000776904535 P RUSTIANI

00766 10/03/2016 Propiltiourasil 100 mg

69

28.174,08

28.174

1362 0000116850813 P AKHMAD HAFILUDDIN

00773 10/03/2016 Amlodipine 5 mg

23

5.505,28

59.174

Lisinopril 10 mg

23

17.664,00

Miniaspi 80 mg

23

4.357,12

Fenofibrate 100 mg

23

31.648,00

1363 0001104077812 P AGUS SANTOSO

00774 10/03/2016 Seretide Diskus 100 100 mcg/puff

1364 0000117004465 P MUHAMAD SYAMSURI

00776 10/03/2016 Miniaspi 80 mg

23

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

9.715,20

Gemfibrozil 600 mg

23

19.989,76

Gliclazide 60 mg

23 161.920,00

Allopurinol 300 mg

23

5.873,28

23

12.659,20

69

9.936,00

1365 0000117073192 I SUNARIYAH

00777 10/03/2016 Glimepiride 4 mg


Metformin 500 mg

1 127.049,58

127.050

4.357,12

393.215

1366 0000774781626 P AKHMAD P.TUS

00778 10/03/2016 Seretide Diskus 100 100 mcg/puff

1367 0000775254475 P HAMIDAH

00779 10/03/2016 Miniaspi 80 mg

23

Micardis 80 mg

23 191.360,00

00798 10/03/2016 Miniaspi 80 mg

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

23 114.816,00

1368 0000774539796 P SUTIYAH

1369 0000202169485 I SITI AMINAH

Halaman :

102

00799 10/03/2016 Micardis 40 mg

22.595

1 127.049,58

127.050

4.357,12

195.717

13.435

114.816

No.

No Ka Peserta

Nama

1370 0001303327844 P MAIMON ABDUL AZIZ

1371 0000776625614 P HALIMAH

No
Rsp

Tgl Pel

Nama Obat

23

Micardis 80 mg

23 191.360,00

Levopar 125 mg komb

46

88.320,00

Metformin 500 mg

46

6.624,00

46

66.828,80

23

3.150,08

23

12.659,20

69

7.418,88

23

12.659,20

69

9.936,00

00807 10/03/2016 Thyrozol 10 mg

00808 10/03/2016 Glimepiride 4 mg


Captopril 25 mg

1373 0000774509286 P BUANI

00814 10/03/2016 Glimepiride 4 mg


Metformin 500 mg

1374 0000173012848 1 ENY SUCI NOVIYANA

00846 11/03/2016 Seretide Diskus 250 250 mcg/puff

1375 0000775460182 P MISTANI

00849 11/03/2016 Miniaspi 80 mg

Furosemide 40 mg
Ramipril 5 mg
1376 0000117054044 P MOHAMAD LUTHFI

1378 0000116967352 P SRIWATI

1379 0000116952041 P MOHAMAD DRADJID

1380 0000117100923 P SUFIATUN

Halaman :

103

4.357,12

Harga
Diajukan
290.661

69.979

20.078

22.595

1 142.799,58

142.800

23

4.357,12

23.935

23

2.502,40

23

17.075,20

23

11.893,76

69

9.936,00

23

9.273,60

Furosemide 40 mg

23

2.502,40

Amlodipine 10 mg

23

9.715,20

00860 11/03/2016 Metformin 850 mg

46

11.628,80

Amlodipine 10 mg

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

Ramipril 5 mg

23

17.075,20

Glimepiride 1 mg

23

7.801,60

23 408.252,43

Amlodipine 10 mg

23

Seretide Diskus 250 250 mcg/puff

1 142.799,58

Diovan 80 mg

23 114.816,00

00863 11/03/2016 Diovan 80 mg

23 114.816,00

00850 11/03/2016 Glimepiride 3 mg


Metformin 500 mg

1377 0001128802419 P MOCH.SAHID

Harga
Obat

00806 10/03/2016 Miniaspi 80 mg

Propranolol 40 mg
1372 0000116918998 P SUBAIDAH

Jml
R/N Obt

00858 11/03/2016 Spironolacton 25 mg

00861 11/03/2016 Spiriva Refill 18 mcg

21.830

21.491

53.993

675.583

9.715,20

133.039

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Amlodipine 10 mg

23

9.715,20

Gemfibrozil 300 mg

23

8.508,16

Harga
Diajukan

1381 0000116862906 P DULKARIM P. MUTARIP

00864 11/03/2016 Miniaspi 80 mg

23

4.357,12

4.357

1382 0000773101203 P SAMHAJI

00865 11/03/2016 Spironolacton 25 mg

23

9.273,60

11.776

Furosemide 40 mg

23

2.502,40

00866 11/03/2016 Furosemide 40 mg

23

2.502,40

Spironolacton 25 mg

23

9.273,60

Amlodipine 10 mg

23

9.715,20

23

33.414,40

33.414

4 430.138,80

670.187

1383 0001453212156 P FAISOL

1384 0000116734825 I ENDANG HASTUTIK

00873 11/03/2016 Thyrozol 10 mg

1385 0000116862928 I MARYAM

00875 11/03/2016 Novorapid Flexpen 100 UI/ml

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

Lantus Solostar 100 UI/ml

2 214.200,00

1386 0000116812721 P DRS. ACHMAD SUBAKKI, 00876 11/03/2016 Amlodipine 10 mg


M.PD
Lisinopril 10 mg

23

9.715,20

23

17.664,00

Furosemide 40 mg

69

7.507,20

Glimepiride 4 mg

23

12.659,20

Lantus Solostar 100 UI/ml

1387 0000774873426 P SALAMA

00877 11/03/2016 Amlodipine 10 mg


Captopril 25 mg

1388 0000774604247 P SUNAH

00878 11/03/2016 Glimepiride 2 mg


Metformin 500 mg

1389 0000117029597 P ABD HADI

00895 11/03/2016 Novorapid Flexpen 100 UI/ml

Halaman :

104

261.746

2 214.200,00

23

9.715,20

69

7.418,88

23

12.835,84

69

9.936,00

17.134

22.772

3 322.604,10

1 107.100,00

00882 12/03/2016 Levopar 125 mg komb

69 132.480,00

132.480

00890 12/03/2016 Vitamin B6 10 mg

23

3.238,40

14.985

Phenytoin 100 mg

69

11.746,56

Lantus Solostar 100 UI/ml


1390 0000116824656 P RADEN HANAFI
HENDRAJANA
1391 0001478151909 P SAFIK

21.491

429.704

No.

No Ka Peserta

Nama

1392 0001479470275 P SUMIATI

No
Rsp

Tgl Pel

Nama Obat

00892 12/03/2016 Thyrozol 10 mg


Propranolol 10 mg

1393 0001094091748 P ABD.KARIM

00903 12/03/2016 Harnal Ocas 0,4 mg


Avodart 0,5 mg

Jml
R/N Obt

Harga
Obat

23

33.414,40

23

1.913,60

23 200.192,00

23 209.024,00
1 142.799,58

142.800
158.269

1394 0000116878162 P SUPRAPTI

00905 12/03/2016 Seretide Diskus 250 250 mcg/puff

1395 0000116841508 P NOOR FATIMATUS


ZACHRAH

00911 12/03/2016 Risperidon 2 mg

46

59.351,04

46

98.918,40

Depakote 250 mg

Harga
Diajukan
35.328

409.216

1396 0000775479273 P HOTIMAH

00914 12/03/2016 Thyrozol 10 mg

23

33.414,40

33.414

1397 0001676182847 P SHALEH

00917 12/03/2016 Harnal Ocas 0,4 mg

23 200.192,00

200.192

1398 0001265208581 P NINING INDRIAWATI

00918 12/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1399 0000116970647 P UDDIN

00919 12/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1400 0001482333535 P FAIZAL AGUSTIAN


PRAMANA
1401 0000166874499 P AHMAD SUHARDI

00921 12/03/2016 Ventolin inhaler 100 mcg/puff

80.325,00

80.325

00922 12/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1402 0000770009545 P SAKUJI

00924 12/03/2016 Thyrozol 10 mg

23

33.414,40

35.328

23

1.913,60

23

33.414,40

33.414

1 142.799,58

142.800
121.676

Propranolol 10 mg
1403 0000116922587 P NY. SALHAH

00925 12/03/2016 Thyrozol 10 mg

1404 0000116778723 P ZAHID

00929 12/03/2016 Seretide Diskus 250 250 mcg/puff

1405 0001968746815 P BUNIKRAH

00930 12/03/2016 Miniaspi 80 mg

23

4.357,12

Furosemide 40 mg

23

2.502,40

Micardis 40 mg

23 114.816,00

1406 0001968748536 P HALIMA

00931 12/03/2016 Bisoprolol 5 mg

23

18.988,80

18.989

1407 0000116983528 P JUHAIRIYAH

00934 12/03/2016 Glimepiride 3 mg

23

11.893,76

203.254

23 191.360,00

1 107.100,00

Micardis 80 mg
1408 0001176647793 P RUSMIATI

00935 12/03/2016 Lantus Solostar 100 UI/ml

117.036

Metformin 500 mg

69

9.936,00

1409 0000117034727 I SITI RAODAH

00939 12/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1410 0000162146643 P HARI YANTO, S.H.I

00940 12/03/2016 Metformin 500 mg

69

9.936,00

80.886

Glimepiride 4 mg

23

12.659,20

Akarbose 100 mg

46

58.291,20

Halaman :

105

No.

No Ka Peserta

Nama

1411 0001429643103 P SUNA

No
Rsp

Tgl Pel

Nama Obat

00941 12/03/2016 Glimepiride 3 mg

23

11.893,76

69

9.936,00

23

11.893,76

69

9.936,00

23

11.893,76

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

46

6.624,00

00942 12/03/2016 Glimepiride 3 mg


Metformin 500 mg

1413 0000116966046 I SITI ROCHANI

Harga
Obat

Metformin 500 mg
1412 0000196656726 I SUNIYAH

Jml
R/N Obt

00947 12/03/2016 Glimepiride 3 mg

Harga
Diajukan
21.830

21.830

27.026

1414 0000777740398 P TALI

00948 12/03/2016 Glimepiride 3 mg

23

11.893,76

11.894

1415 0001874550014 P SULALAH

00950 12/03/2016 Allopurinol 100 mg

23

2.531,84

109.632

Lantus Solostar 100 UI/ml


1416 0000116966035 P SOEGI PRABOWO

1 107.100,00

00951 12/03/2016 Lisinopril 10 mg

23

17.664,00

Bisoprolol 5 mg

11

9.081,60

26.746

1417 0000117125594 P SITI TITIK FARHATIN

00955 12/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1418 0000172426015 S SAMSUL IMAM

00956 12/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1419 0000117092968 P MOHAMMAD BADWI

00957 12/03/2016 Clorilex 100 100 mg

12

76.800,00

79.950

23

3.150,08

23

6.300,16

23

3.297,28

Vitamin - B Complex komb


1420 0000116559944 P MUHAMAD TRISWARNO

00958 12/03/2016 Alprazolam 0,5 mg


Amitriptyline 25 mg

9.597

1421 0000117006254 P ABDUL KADIR JAMALI

00962 12/03/2016 Furosemide 40 mg

23

2.502,40

2.502

1422 0001961273518 P WINARTI

00964 12/03/2016 Metformin 500 mg

69

9.936,00

9.936

1423 0000775245317 P ROKAYYAH

00965 12/03/2016 Propranolol 10 mg

69

5.740,80

24.524

46

18.782,72

Propiltiourasil 100 mg
1424 0001106407596 P SISILIA KLIANI

00966 12/03/2016 Olandoz 5 5 mg

23 189.888,00

189.888

1425 0000114179962 P ABD. KAHIR

00967 12/03/2016 Glimepiride 4 mg

23

12.659,20

22.595

Metformin 500 mg

69

9.936,00

00968 12/03/2016 Amlodipine 10 mg

23

9.715,20

23 114.816,00

1426 0000116916568 P RUSMIYATI

Diovan 80 mg

124.531

1427 0000117044842 I KASMI

00973 12/03/2016 Glimepiride 3 mg

23

11.893,76

11.894

1428 0001195095767 P INTAN RAHMAWATI

00976 12/03/2016 Alprazolam 0,5 mg

23

6.300,16

118.090

Halaman :

106

No.

No Ka Peserta

Nama

1429 0001447399451 P ABD.RAHMAN

1430 0000117056812 1 RAMZAN BARID

No
Rsp

Tgl Pel

Nama Obat

Harga
Obat

Harga
Diajukan

Nopres 20 mg

23

12.718,08

Olandoz 5 5 mg

12

99.072,00

23

11.893,76

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

69

9.936,00

46

14.425,60

46 379.776,00

23 114.816,00

114.816

23

9.715,20

33.061

Bisoprolol 5 mg

23

18.988,80

Miniaspi 80 mg

23

4.357,12

00978 12/03/2016 Glimepiride 3 mg

00979 12/03/2016 Carbamazepine 200 mg


Olandoz 5 5 mg

1431 0000116984193 P MAZHAR

Jml
R/N Obt

00980 12/03/2016 Diovan 80 mg

1432 0000116986509 P SITTI ROKAYYAH NASIR 00987 14/03/2016 Amlodipine 10 mg

30.338

394.202

1433 0000117065608 I MIYATI

00988 14/03/2016 Glimepiride 1 mg

23

7.801,60

7.802

1434 0001282144184 P JUMA'I

00991 14/03/2016 Isosorbid Dinitrat 5 mg

69

7.772,16

48.252

Bisoprolol 5 mg

23

18.988,80

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Captopril 25 mg

69

7.418,88

23

2.502,40

23 114.816,00

23

Clorilex 100 100 mg

23 147.200,00

Klorpromazin 100 mg

35

6.451,20

69

7.418,88

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

1435 0000116888679 P PRAJITNO SUDARSONO


BMS.

00992 14/03/2016 Furosemide 40 mg


Micardis 40 mg

1436 0000116934917 P FADLI

1437 0000116890402 P SITI MUTMAINAH

00993 14/03/2016 Depakote ER 250 mg

00997 14/03/2016 Captopril 25 mg

82.225,92

117.318

235.877

30.014

1438 0001048422429 P MOHAMMAD RAMLI

00999 14/03/2016 Amlodipine 5 mg

23

5.505,28

5.505

1439 0000117029485 I ROFIATUS SYARIFAH

01005 14/03/2016 Amlodipine 10 mg

23

9.715,20

32.310

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

Halaman :

107

No.

No Ka Peserta

Nama

1440 0001896947008 P SITI RAMLAH

1441 0001388730036 P ABD.HAMID

No
Rsp

Tgl Pel

Nama Obat

01006 14/03/2016 Micardis 80 mg

1443 0000117008289 P SITI SUKARNI

Harga
Obat

23 191.360,00

Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

69

7.507,20

23

12.659,20

69

9.936,00

23

7.212,80

Haloperidol 0,5 mg

46

3.473,92

Vitamin B6 10 mg

R.01

23

3.238,40

Phenytoin 100 mg

R.01

23

3.915,52

23

9.715,20

23

11.893,76

01007 14/03/2016 Glimepiride 4 mg


Metformin 500 mg

1442 0000197467569 1 NURCHOLIS SETIAWAN


ALI

Jml
R/N Obt

01010 14/03/2016 Carbamazepine 200 mg

01018 14/03/2016 Amlodipine 10 mg


Glimepiride 3 mg

1444 0000169910662 I ANIFATUR RAHMAH

01033 14/03/2016 Seretide Diskus 250 250 mcg/puff

1445 0000098119484 P SUDARTO

01034 14/03/2016 Glikuidon 30 mg

Captopril 25 mg

Harga
Diajukan
208.582

22.595

17.841

21.609

1 142.799,58

142.800

23

27.968,00

35.387

69

7.418,88

1446 0001428377196 P IMAM HANAFI

01035 14/03/2016 Simvastatin 20 mg

23

11.511,04

11.511

1447 0000116798321 I SILVIANA

01036 14/03/2016 Fenofibrate 100 mg

23

31.648,00

31.648

1448 0000203414905 I SITI HOSNIYAH

01038 14/03/2016 Glimepiride 3 mg

23

11.893,76

11.894

1449 0000210456898 S SYAIFUL UMRON

01039 14/03/2016 Glimepiride 4 mg

23

12.659,20

80.886

Akarbose 100 mg

46

58.291,20

Metformin 500 mg

69

9.936,00

23

33.414,40

23

1.913,60

23

12.835,84

46

6.624,00

23

9.273,60

23

2.502,40

46

66.828,80

69

5.740,80

23

11.893,76

1450 0000776259729 P HASAN

01040 14/03/2016 Thyrozol 10 mg


Propranolol 10 mg

1451 0001423361586 P YUK AMALIA

01041 14/03/2016 Glimepiride 2 mg


Metformin 500 mg

1452 0000776677522 P M RUJI

01042 14/03/2016 Spironolacton 25 mg


Furosemide 40 mg

1453 0000773872446 P SAYUMI

01043 14/03/2016 Thyrozol 10 mg


Propranolol 10 mg

1454 0002033907748 P FAHRUR ROSI

Halaman :

108

01072 14/03/2016 Glimepiride 3 mg

35.328

19.460

11.776

72.570

11.894

No.

No Ka Peserta

Nama

1455 0001315837348 P MOSLEH

No
Rsp

Tgl Pel

Nama Obat

01077 14/03/2016 Amlodipine 10 mg


Allopurinol 300 mg

Jml
R/N Obt

Harga
Obat

23

9.715,20

23

5.873,28

23

9.715,20

9.715

1 142.799,58

142.800
7.831

1456 0000116950037 P MOH.AMIN MUZAMMIL

01079 14/03/2016 Amlodipine 10 mg

1457 0000772624089 P PUSIHA

01103 15/03/2016 Seretide Diskus 250 250 mcg/puff

1458 0000114817127 I SUPATYA

01105 15/03/2016 Miniaspi 80 mg

23

4.357,12

46

3.473,92

23

9.715,20

23

17.664,00

23

4.357,12

23

5.505,28

Haloperidol 0,5 mg
1459 0000117093363 P BUNAMIN

01106 15/03/2016 Amlodipine 10 mg


Lisinopril 10 mg

1460 0001104491619 P YUDI SANTOSO

01111 15/03/2016 Miniaspi 80 mg


Amlodipine 5 mg

1461 0000094685084 I SRI SUNINGSIH

01112 15/03/2016 Lantus Solostar 100 UI/ml


Allopurinol 100 mg

Harga
Diajukan

1 107.100,00

23

2.531,84

15.588

27.379

9.862

109.632

1462 0000116984744 P MOJIONO

01117 15/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1463 0001795026993 P MOHAMMAD HASAN

01118 15/03/2016 Lisinopril 5 mg

23

10.304,00

10.304

1464 0000116986083 P SAMHUDI

01121 15/03/2016 Amlodipine 10 mg

23

9.715,20

27.379

Lisinopril 10 mg

23

17.664,00

1465 0000116983427 P INDHARIYAH MUSTIKA

01126 15/03/2016 Micardis 40 mg

23 114.816,00

114.816

1466 0001155718539 P ISMAIL

01128 15/03/2016 Vitamin B6 10 mg

16

2.252,80

13.999

Phenytoin 100 mg

69

11.746,56

1467 0000116912878 I SUHAINANINGSIH

01135 15/03/2016 Seretide Diskus 250 250 mcg/puff

109

1 142.799,58

Miniaspi 80 mg

23

4.357,12

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Diovan 80 mg

23 114.816,00

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Gemfibrozil 300 mg

23

8.508,16

Allopurinol 100 mg

23

2.531,84

1468 0000117979659 1 HIKMATUL ARIDA HUSNA 01136 15/03/2016 Amlodipine 10 mg

Halaman :

281.521

38.419

No.

No Ka Peserta

Nama

1469 0000116422896 P MOH. RIDWAN

No
Rsp

Tgl Pel

Nama Obat

01137 15/03/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

1470 0000774156688 S SUCIPTO

01152 15/03/2016 Thyrozol 10 mg

1472 0000116900245 I SUHENAH

Harga
Obat

5 537.673,50

1 107.100,00

46

66.828,80

69

5.740,80

01153 15/03/2016 Glimepiride 4 mg

23

12.659,20

Akarbose 100 mg

46

58.291,20

01154 15/03/2016 Amlodipine 10 mg

23

9.715,20

23

12.835,84

Propranolol 10 mg
1471 0000116992427 P MAS`AT

Jml
R/N Obt

Glimepiride 2 mg

Harga
Diajukan
644.774

72.570

70.950

22.551

1473 0000159399516 P SITI SUPRAPTI

01155 15/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1474 0001389542163 P ELLY FRIAH NINGSIH

01156 15/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1475 0000776138859 P HALIFAH

01158 15/03/2016 Amlodipine 5 mg

23

5.505,28

8.008

23

2.502,40

Furosemide 40 mg
1476 0000775363781 P MOH.HARIRI

01159 15/03/2016 Thyrozol 5 mg

46

33.149,44

33.149

1477 0000116937584 P HALIMAH


JD.ABD.RACHMAN

01177 15/03/2016 Gliclazide 60 mg

23 161.920,00

165.232

23

Metformin 500 mg
1478 0000117027707 P MUDJI

1479 000081443474

01190 15/03/2016 Novorapid Flexpen 100 UI/ml

Gemfibrozil 300 mg

Lantus Solostar 100 UI/ml

P MOH. HAIRUDIN SASTRA 01191 15/03/2016 Glicab 80 mg

3.312,00

2 215.069,40
23

330.678

8.508,16

1 107.100,00

46

13.895,68

69

9.936,00

23

9.273,60

Furosemide 40 mg

12

1.305,60

1481 0001048583597 P SA'IHA

01200 15/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1482 0000116813136 P HADI

01206 15/03/2016 Glimepiride 2 mg

23

12.835,84

22.772

Metformin 500 mg

69

9.936,00

01210 15/03/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

Captopril 25 mg

69

7.418,88

01213 15/03/2016 Thyrozol 10 mg

46

66.828,80

Metformin 500 mg
1480 0000775014581 P MARROH

1483 0000774043244 P MAHMUDI

1484 0001048377284 P HAZIZAH

Halaman :

110

01193 15/03/2016 Spironolacton 25 mg

23.832

10.579

22.404

68.742

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Propranolol 10 mg

Jml
R/N Obt

Harga
Obat

23

1.913,60

Harga
Diajukan

1485 0001895626462 P SUKARLANA

01217 15/03/2016 Ramipril 5 mg

23

17.075,20

17.075

1486 0001048339304 P MAS AH

01220 15/03/2016 Metformin 500 mg

69

9.936,00

9.936

1487 0000116985115 P H.N. SUGIARTO

01235 16/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1488 0000116985126 I SUTJI AMINGSIH

01236 16/03/2016 Amlodipine 10 mg

23

9.715,20

362.995

Gliclazide 60 mg

23 161.920,00

Micardis 80 mg

23 191.360,00

23

12.835,84

Metformin 500 mg

69

9.936,00

Simvastatin 20 mg

23

11.511,04

23

11.893,76

69

7.418,88

23

4.357,12

69

7.772,16

1489 0000117080144 P DRS. SULAIMAN

1490 0000204334334 P EMAD

01260 16/03/2016 Glimepiride 2 mg

01264 16/03/2016 Glimepiride 3 mg


Captopril 25 mg

1491 0000776536907 P HOLILAH

01265 16/03/2016 Miniaspi 80 mg


Isosorbid Dinitrat 5 mg

34.283

19.313

12.129

1492 0000117071425 I DJUMAATI

01266 16/03/2016 Captopril 25 mg

23

2.472,96

2.473

1493 0000117508184 P SUHARSO

01270 16/03/2016 Glimepiride 3 mg

23

11.893,76

30.338

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

69

9.936,00

23

11.893,76

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

69

9.936,00

Allopurinol 100 mg

23

2.531,84

1494 0000117508195 I SAHAMI

01271 16/03/2016 Glimepiride 3 mg

1495 0000780402251 P AGUS

01275 16/03/2016 Top Up Hemofilia RS B Reg I NULL

1496 0000777427301 P SAFATUN

01280 16/03/2016 Micardis 80 mg

1 7.914.200,0
0
23 191.360,00

69

Metformin 500 mg

32.870

7.914.200
201.296

9.936,00

1497 0000116894913 P DJASSULI

01282 16/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1498 0000116894924 I RUMIYAH

01283 16/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1499 0000773664096 P JAHRAWI

01287 16/03/2016 Symbicort 160/4.5mcg

1 148.176,00

148.176

1500 0000098228834 P ABD. KAMAR

01290 16/03/2016 Amlodipine 10 mg

9.715,20

9.715

Halaman :

111

23

No.

No Ka Peserta

Nama

1501 0001325427355 P HAFIFAH

No
Rsp

Tgl Pel

Nama Obat

01291 16/03/2016 Micardis 80 mg

Jml
R/N Obt

Harga
Obat

23 191.360,00

Novorapid Flexpen 100 UI/ml

5 537.673,50

Furosemide 40 mg

23

2.502,40

Allopurinol 300 mg

23

5.873,28

Lantus Solostar 100 UI/ml

1 107.100,00
1 107.534,70

107.535
9.921

1502 0000116960196 P RAMLAH

01292 16/03/2016 Novorapid Flexpen 100 UI/ml

1503 0000116912632 P MOH. TOHA

01295 16/03/2016 Furosemide 40 mg

23

2.502,40

Captopril 25 mg

69

7.418,88

01296 16/03/2016 Thyrozol 10 mg

46

66.828,80

23

3.150,08

1504 0001971820989 P IMANIYAH

Harga
Diajukan

Propranolol 40 mg

844.509

69.979

1505 0001048724572 P DIWI

01305 16/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1506 0000117127539 P DWI SWESTIARI

01308 16/03/2016 Lisinopril 10 mg

23

17.664,00

17.664

1507 0001437919301 P SUHATI

01312 16/03/2016 Glimepiride 3 mg

23

11.893,76

11.894

1508 0000775310365 P LUBABAH

01312 16/03/2016 Glimepiride 4 mg

23

12.659,20

27.526

Metformin 500 mg

46

6.624,00

Captopril 50 mg

46

8.243,20

1509 0001304829246 P AMIN FAIZ

01319 16/03/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

1510 0000209712251 P SURATININGSIH

01320 16/03/2016 Micardis 40 mg


Novomix Flexpen 100 UI/ml

1511 0000774203692 P HAMIDAH

01326 16/03/2016 Thyrozol 10 mg

1513 0000116852444 P SAHURI

Halaman :

112

2 215.069,40

1 107.100,00

23 114.816,00

3 400.680,00

23

33.414,40

46

3.827,20

01331 17/03/2016 Akarbose 50 mg

46

45.926,40

Gliclazide 60 mg

23 161.920,00

Metformin 500 mg

69

9.936,00

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Novorapid Flexpen 100 UI/ml

3 322.604,10

Lantus Solostar 100 UI/ml

1 107.100,00

Propranolol 10 mg
1512 0000117122962 P A SUGIANTO

01332 17/03/2016 Miniaspi 80 mg

322.169

515.496

37.242

217.782

443.776

No.

No Ka Peserta

Nama

1514 0000116991753 P MOHAMMAD JUFFRI

1515 0000116926244 P ABD. SAMAD, A.MA

1516 0000116926255 I MUSLIMAH

No
Rsp

Tgl Pel

Nama Obat

01333 17/03/2016 Micardis 80 mg

Jml
R/N Obt

Harga
Obat

23 191.360,00

Glikuidon 30 mg

23

27.968,00

Furosemide 40 mg

23

2.502,40

Fenofibrate 100 mg

23

31.648,00

Lantus Solostar 100 UI/ml

01338 17/03/2016 Miniaspi 80 mg

360.578

1 107.100,00

23

4.357,12

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

23 161.920,00

Furosemide 40 mg

12

1.305,60

Metformin 500 mg

69

9.936,00

01339 17/03/2016 Gliclazide 60 mg

Harga
Diajukan

21.403

173.162

1517 0000163351405 I SUKARTINI

01349 17/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1518 0000116950871 P MOH. MAHAT

01351 17/03/2016 Spiriva Refill 18 mcg

23 408.252,43

535.302

1 127.049,58

Seretide Diskus 100 100 mcg/puff


1519 0001891626748 P RUHANA

01355 17/03/2016 Glimepiride 4 mg

23

12.659,20

69

7.772,16

01360 17/03/2016 Trifluoperazin 5 mg

R.01

23

11.923,20

Haloperidol 0,5 mg

R.01

46

3.473,92

Amitriptyline 25 mg

R.01 11,5

1.648,64

Isosorbid Dinitrat 5 mg
1520 0001110150347 P SARWONO

1521 0000776857149 P SU'UD

1522 0001824409888 P HJ.MUKARROMAH

01361 17/03/2016 Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Levopar 125 mg komb

46

88.320,00

01389 17/03/2016 Isosorbid Dinitrat 5 mg

69

7.772,16

23

4.357,12

Miniaspi 80 mg

20.431

17.046

102.392

12.129

1523 0001266413264 P KOMARIYATUN

01390 17/03/2016 Propranolol 10 mg

46

3.827,20

3.827

1524 0001048397218 P SURAHMI

01391 17/03/2016 Glimepiride 4 mg

23

12.659,20

25.127

Metformin 500 mg

69

9.936,00

Allopurinol 100 mg

23

2.531,84

23

9.715,20

1525 0001048747757 P DULAMA

Halaman :

113

01401 17/03/2016 Amlodipine 10 mg

27.379

No.

No Ka Peserta

Nama

1526 0002037201221 P NURASIYAH

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Lisinopril 10 mg

23

01402 17/03/2016 Micardis 80 mg

23 191.360,00

23

5.873,28

Allopurinol 300 mg

Harga
Diajukan

17.664,00
197.233

1527 0000116746558 P ZAINAL ABIDIN

01403 17/03/2016 Captopril 25 mg

69

7.418,88

7.419

1528 0002038167819 P MOH.LUTFI

01404 17/03/2016 Glimepiride 3 mg

23

11.893,76

21.830

69

9.936,00

Metformin 500 mg
1529 0000116987782 P UMI FATIROH

01410 17/03/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

5 537.673,50

2 214.200,00

751.874

1530 0000774193792 P SALUKI

01411 17/03/2016 Micardis 40 mg

23 114.816,00

114.816

1531 0000116982573 P FATIMAH FANKIYAH

01420 17/03/2016 Olandoz 10 10 mg

23 329.728,00

359.726

Nopres 20 mg

23

12.718,08

Klobazam 10 mg

15

17.280,00

23 329.728,00

Nopres 20 mg

23

12.718,08

Klobazam 10 mg

15

17.280,00

Candesartan Cilexetil 8 mg

23

91.264,00

23 107.956,48

Micardis 80 mg

23 191.360,00

Bisoprolol 5 mg

23

18.988,80

01423 17/03/2016 Thyrozol 10 mg

23

33.414,40

23

3.150,08

23

33.414,40

23

1.913,60

1532 0000116932904 P DR.HANDOJO,MPH

1533 0001795802398 P FAJARIYAH MULYANI

1534 0000775526951 P NATIFAH

01421 17/03/2016 Olandoz 10 10 mg

01422 17/03/2016 Herbesser CD 100 mg

Propranolol 40 mg
1535 0001200312955 P RYAN YULITA

01424 17/03/2016 Thyrozol 10 mg


Propranolol 10 mg

450.990

318.305

36.564

35.328

1536 0001093275472 P M.ZAINAL ABIDIN

01425 17/03/2016 Micardis 80 mg

23 191.360,00

191.360

1537 0000116978411 P LIMANI

01426 17/03/2016 Amlodipine 10 mg

23

9.715,20

146.361

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

Micardis 40 mg

23 114.816,00

23

1538 0001095194215 P SUMIK

Halaman :

114

01429 17/03/2016 Gemfibrozil 300 mg

8.508,16

52.742

No.

No Ka Peserta

Nama

1539 0001279734884 P EKO MARDIONO

1540 0000774780557 P HAMILAH

No
Rsp

Tgl Pel

Nama Obat

Harga
Obat

Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Miniaspi 80 mg

23

4.357,12

Allopurinol 300 mg

23

5.873,28

Metformin 500 mg

46

6.624,00

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Seretide Diskus 250 250 mcg/puff

01434 17/03/2016 Isosorbid Dinitrat 5 mg

01436 17/03/2016 Miniaspi 80 mg

23

4.357,12

69

7.772,16

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

01439 17/03/2016 Miniaspi 80 mg

Harga
Diajukan

164.644

1 142.799,58

Isosorbid Dinitrat 5 mg
1541 0000774511828 P RISKIYAH

Jml
R/N Obt

12.129

13.435

1542 0000773739663 P ROFIKI

01440 17/03/2016 Bisoprolol 5 mg

12

9.907,20

9.907

1543 0000117087456 P SULAIMAN

01443 17/03/2016 Glimepiride 2 mg

23

12.835,84

169.221

Gemfibrozil 300 mg

23

8.508,16

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Micardis 40 mg

23 114.816,00

01446 18/03/2016 Miniaspi 80 mg

23

4.357,12

69

7.772,16

23

9.715,20

23 144.256,00

23

33.414,40

23

1.913,60

1544 0001839722771 P SULIHA

Isosorbid Dinitrat 5 mg
1545 0000116984395 P MOH ALI HEFNI

01456 18/03/2016 Amlodipine 10 mg


Candesartan Cilexetil 16 mg

1546 0000775898155 P MISPARI

01464 18/03/2016 Thyrozol 10 mg


Propranolol 10 mg

12.129

153.971

35.328

1547 0000116932509 P DJUHAIRIJAH

01466 18/03/2016 Gliclazide 60 mg

23 161.920,00

161.920

1548 0000147812038 P ABU HASAN, A.PRA.TTD

01472 18/03/2016 Micardis 80 mg

23 191.360,00

203.607

Halaman :

115

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Amlodipine 10 mg

23

9.715,20

Allopurinol 100 mg

23

2.531,84

Harga
Diajukan

1549 0001896757402 P MARYAMAH

01478 18/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1550 0001859563596 P NURIYAMI

01482 18/03/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

322.169

1 107.100,00
1 127.049,58

127.050
18.518

Lantus Solostar 100 UI/ml


1551 0000117516161 P SUSI AGUSTIN, AMA.PD

01483 18/03/2016 Seretide Diskus 100 100 mcg/puff

1552 0000775159198 P AMINA

01484 18/03/2016 Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

46

6.624,00

01487 18/03/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

69

9.936,00

23

12.659,20

46

66.828,80

Propranolol 10 mg

46

3.827,20

01499 19/03/2016 Amlodipine 10 mg

23

9.715,20

Allopurinol 300 mg

23

5.873,28

Candesartan Cilexetil 16 mg

23 144.256,00

1553 0000117070503 P HARIS

Glimepiride 4 mg
1554 0000776569184 P HOTIJA

01495 19/03/2016 Metformin 500 mg


Glimepiride 4 mg

1555 0000775628436 P MUSARROFAH

1556 0000116985936 P SAFIYAH

01497 19/03/2016 Thyrozol 10 mg

22.595

22.595

70.656

159.844

1557 0001431541719 P HOSNIYAH

01502 19/03/2016 Clorilex 100 100 mg

38.400,00

38.400

1558 0000116833915 P MOH. HAKI

01507 19/03/2016 Miniaspi 80 mg

23

4.357,12

9.303

46

4.945,92

Captopril 25 mg
1559 0000117369617 P ACHMAD AS'AD

01514 19/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1560 0000116995858 I RUSMIYATI

01522 19/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1561 0000049204271 P HATIMAH

01525 19/03/2016 Miniaspi 80 mg

23

4.357,12

39.597

Amlodipine 5 mg

23

5.505,28

Isosorbid Dinitrat 5 mg

69

7.772,16

Concor 2,5 mg

23

21.962,24

1562 0000117432753 P DRA. SRI AGUSTINI

01529 19/03/2016 Seretide Diskus 100 100 mcg/puff

1563 0000117017785 P ABD RAHMAN

01530 19/03/2016 Glimepiride 2 mg

1564 0000774902891 P SITI NUR SATRIA

01531 19/03/2016 Thyrozol 10 mg

Halaman :

116

1 127.049,58

127.050

23

12.835,84

12.836

46

66.828,80

72.570

No.

No Ka Peserta

Nama

1565 0000776168515 P MOH.HEKAM

1566 0000773893991 P MARSUDAH

No
Rsp

Tgl Pel

Nama Obat

1568 0000773872378 P SALAMET

69

5.740,80

01532 19/03/2016 Vitamin B6 10 mg

23

3.238,40

Carbamazepine 200 mg

R.01 1,38

432,77

Phenytoin 100 mg

R.02 20,7

3.523,97

01533 19/03/2016 Thyrozol 10 mg

23

33.414,40

23

1.913,60

23

11.893,76

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

69

9.936,00

23

4.357,12

69

7.772,16

38.400,00

23

6.300,16

01534 19/03/2016 Glimepiride 3 mg

01535 19/03/2016 Miniaspi 80 mg


Isosorbid Dinitrat 5 mg

1569 0001326019331 P UMMU SALAMAH

01536 19/03/2016 Clorilex 100 100 mg


Alprazolam 0,5 mg

1570 0000117062605 P ABDUL QADIR DJAELANI 01538 19/03/2016 Seretide Diskus 100 100 mcg/puff

1571 0000116935953 I HJ. SITI NURHAYATI

1573 0001304457513 P JUMANI

1574 0000117097457 P MAS`UDI

1575 0000774578654 P NUR FADILAH

Halaman :

117

7.195

35.328

30.338

12.129

44.700

127.050

23

5.505,28

25.495

23

19.989,76

69

21.638,40

Alprazolam 0,5 mg

23

6.300,16

Vitamin B6 10 mg

23

3.238,40

01544 19/03/2016 Amlodipine 5 mg

01545 19/03/2016 Carbamazepine 200 mg

01546 19/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

Spironolacton 25 mg

23

9.273,60

Bisoprolol 5 mg

23

18.988,80

Clopidogrel 75 mg

23 100.096,00

23

01547 19/03/2016 Lansoprazole 30 mg

13.925,12

Seretide Diskus 100 100 mcg/puff

Amlodipine 5 mg

23

5.505,28

23

6.300,16

46 379.776,00

01548 19/03/2016 Alprazolam 0,5 mg


Olandoz 5 5 mg

1576 0000117126369 1 DWI CANDRA BAGUS K.

Harga
Diajukan

1 127.049,58

Gemfibrozil 600 mg
1572 0000117484817 P NOR AHMAD

Harga
Obat

Propranolol 10 mg

Propranolol 10 mg
1567 0000116935942 P H. MOH. ALWI

Jml
R/N Obt

01551 19/03/2016 Clorilex 100 100 mg

31.177

255.408

146.480

1 127.049,58

38.400,00

386.076

97.751

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Risperidon 2 mg

Jml
R/N Obt

Harga
Obat

46

59.351,04

Harga
Diajukan

1577 0001095524886 P NURUL HIDAYAT

01554 19/03/2016 Glimepiride 1 mg

23

7.801,60

7.802

1578 0001482889037 P SUGIYONO

01559 21/03/2016 Trifluoperazin 5 mg

46

23.846,40

104.886

Clorilex 100 100 mg

12

76.800,00

Klorpromazin 100 mg

23

4.239,36

01560 21/03/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

7.212,80

Phenytoin 100 mg

69

11.746,56

Vitamin B6 10 mg

23

3.238,40

46

33.149,44

Propranolol 10 mg

69

5.740,80

01570 21/03/2016 Furosemide 40 mg

12

1.305,60

Amlodipine 10 mg

23

9.715,20

Captopril 50 mg

69

12.364,80

01583 21/03/2016 Thyrozol 10 mg

23

33.414,40

46

3.827,20

12

8.908,80

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

23 161.920,00

Gemfibrozil 300 mg

23

8.508,16

Allopurinol 100 mg

23

2.531,84

46

66.828,80

69

5.740,80

23

4.357,12

Amlodipine 5 mg

23

5.505,28

Gemfibrozil 300 mg

23

8.508,16

23

2.502,40

1579 0000773943884 P ROHMAN SODIK

1580 0000777784127 P SUBAIRI

1581 0000775228105 P FADILAH

1582 0000117516611 I ERNAWATI

1583 0000117016165 P LILIK SULAIHA

01566 21/03/2016 Carbamazepine 200 mg

01569 21/03/2016 Thyrozol 5 mg

Propranolol 10 mg
1584 0000774764763 P SULASTRI

1585 0000116816016 P SUPARMAN

1586 0000774820236 P SITTI FATMA

01584 21/03/2016 Ramipril 5 mg

01591 21/03/2016 Gliclazide 60 mg

01598 21/03/2016 Thyrozol 10 mg


Propranolol 10 mg

1587 0000775815805 P HAMIMAH

1588 0001295565377 P SIRAD

Halaman :

118

01599 21/03/2016 Miniaspi 80 mg

01600 21/03/2016 Furosemide 40 mg

14.985

22.198

38.890

23.386

37.242

20.685

172.960

72.570

18.371

19.578

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Ramipril 5 mg

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

23

69 132.480,00

132.480

1590 0000116986509 P SITTI ROKAYYAH NASIR 01617 21/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1591 0001894864252 P MUAYYAH

46

3.827,20

20.402

23

16.574,72

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

Metformin 500 mg

69

9.936,00

1589 0001410230518 P MUSLIMAH

01613 21/03/2016 Levopar 125 mg komb

01621 21/03/2016 Propranolol 10 mg


Thyrozol 5 mg

1592 0000116847832 P MOHAMMAD BADRUL

01622 21/03/2016 Miniaspi 80 mg

17.075,20

23.371

1593 0001048553109 P DESI ANDRIANI PAUSI

01626 21/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1594 0001372475305 P HARI GUNAWAN

01627 21/03/2016 Micardis 80 mg

23 191.360,00

193.862

23

2.502,40

Furosemide 40 mg
1595 0000098244257 I HASIJAH

01630 21/03/2016 Glimepiride 3 mg

23

11.893,76

11.894

1596 0001876227254 P MA.SYAKUR

01645 21/03/2016 Micardis 80 mg

23 191.360,00

203.578

Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

1597 0001301260364 P BUSTAMI

01648 21/03/2016 Novorapid Flexpen 100 UI/ml

1598 0000777308499 P ABD SAKUR

01654 21/03/2016 Carbamazepine 200 mg

Vitamin B6 10 mg
Phenytoin 100 mg
1599 0000173585316 P SUPRIYADI

1600 0000199657225 I UMI SULCHAH

2 215.069,40

215.069

23

7.212,80

22.198

23

3.238,40

69

11.746,56

23

11.893,76

Captopril 12,5 mg

69

5.475,84

Allopurinol 100 mg

23

2.531,84

01667 22/03/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

69

7.772,16

Amlodipine 10 mg

23

9.715,20

Miniaspi 80 mg

23

4.357,12

01680 22/03/2016 Micardis 80 mg

23 191.360,00

01662 21/03/2016 Glimepiride 3 mg

Glimepiride 4 mg
1601 0001048545955 P LENI IRAWATI

1602 0000774712901 P HAMIDAH

Halaman :

119

01675 22/03/2016 Isosorbid Dinitrat 5 mg

19.901

22.595

21.844

191.360

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

1603 0000116902934 P ACH BUHARI

01685 22/03/2016 Harnal D 0,2 mg

23 170.752,00

170.752

1604 0001871901257 P SATRAEH

01689 22/03/2016 Miniaspi 80 mg

23

4.357,12

34.209

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Lisinopril 5 mg

23

10.304,00

46

14.425,60

Amlodipine 10 mg

23

9.715,20

Phenytoin 100 mg

23

3.915,52

23 191.360,00

23

8.508,16

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Gemfibrozil 300 mg

23

8.508,16

23 161.920,00

Metformin 500 mg

69

9.936,00

Akarbose 100 mg

46

58.291,20

1609 0002034135101 P MOH. ASMONI

01709 22/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1610 0000117129486 P MOH SALEH LAHADI

01710 22/03/2016 Captopril 12,5 mg

23

1.825,28

1.825

1611 0000774393614 P GUNAWAN AGUS


SUSANTO

01715 22/03/2016 Clorilex 100 100 mg

38.400,00

97.751

46

59.351,04

23

7.212,80

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

1605 0000160642539 P RUSDARWATI

1606 0001105344382 P HANDRI JEMMI SAMPEL

01691 22/03/2016 Carbamazepine 200 mg

01695 22/03/2016 Micardis 80 mg


Gemfibrozil 300 mg

1607 0000775644276 P MISKIYAH

1608 0000117370091 P H.MASJHURI

01703 22/03/2016 Amlodipine 10 mg

01704 22/03/2016 Gliclazide 60 mg

Risperidon 2 mg
1612 0000775174612 P ABD RAHMAN

01716 22/03/2016 Carbamazepine 200 mg

28.056

199.868

37.212

230.147

22.198

1613 0000116909998 P MAMNU'AH, A.MA

01721 22/03/2016 Diovan 80 mg

23 114.816,00

114.816

1614 0001048374922 P SAMI

01732 22/03/2016 Thyrozol 10 mg

46

66.828,80

72.570

69

5.740,80

23

12.659,20

69

9.936,00

Propranolol 10 mg
1615 0001276375948 P MAIMUN

01735 22/03/2016 Glimepiride 4 mg


Metformin 500 mg

Halaman :

120

22.595

No.

No Ka Peserta

Nama

1616 0001311944365 P ATIYEH

1617 0000777224676 P NOR HAMZAH

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

01739 22/03/2016 Furosemide 40 mg

69

7.507,20

Amlodipine 10 mg

23

9.715,20

Captopril 25 mg

69

7.418,88

23

9.715,20

69

7.418,88

01740 22/03/2016 Amlodipine 10 mg


Captopril 25 mg

Harga
Diajukan
24.641

17.134

1618 0001814601194 P SITI MARYAM

01748 22/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1619 0000774381701 P SUNDARI

01752 22/03/2016 Glikuidon 30 mg

23

27.968,00

30.470

23

2.502,40

23 191.360,00

Novorapid Flexpen 100 UI/ml

3 322.604,10

Lantus Solostar 100 UI/ml

1 107.100,00

Furosemide 40 mg
1620 0000116932116 P DJAMALIYAH

1621 0001410235659 P SYAIFUL ZAIN

01756 22/03/2016 Micardis 80 mg

01777 23/03/2016 Ramipril 5 mg

23

17.075,20

Isosorbid Dinitrat 5 mg

69

7.772,16

Miniaspi 80 mg

23

4.357,12

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

1623 0001891796499 P MOHAMMAD MUTAMMAM 01793 23/03/2016 Olandoz 10 10 mg

23 329.728,00

46

23.846,40

01797 23/03/2016 Akarbose 100 mg

46

58.291,20

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

01798 23/03/2016 Alprazolam 0,5 mg

23

6.300,16

46 379.776,00

23

12.659,20

69

9.936,00

1622 0000116828032 P SLAMET AGUSTIAWAN

01782 23/03/2016 Amlodipine 10 mg

Trifluoperazin 5 mg
1624 0000116987062 P SUKRAH

1625 0001048494688 P ERFAN ARIFANDI

Olandoz 5 5 mg
1626 0000774148397 P BUSIYAH

01802 23/03/2016 Glimepiride 4 mg


Metformin 500 mg

1627 0000777171969 P MOH.ROMALI

01810 23/03/2016 Symbicort 80/4.5mcg

1628 0000117021227 P MOHAMAD HARIYADI D

01811 23/03/2016 Amlodipine 5 mg

Halaman :

121

621.064

29.204

42.364

353.574

80.886

386.076

22.595

1 139.230,00

139.230

5.505,28

20.490

23

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

1629 0000173770918 2 ANISATUL KAMILAH

01813 23/03/2016 Propranolol 40 mg

12

1.643,52

1.644

1630 0000116934671 P EMMA JD HOSEN

01820 23/03/2016 Miniaspi 80 mg

23

4.357,12

5.663

12

1.305,60

Furosemide 40 mg
1631 0000774994083 P ABD.KAWI

01822 23/03/2016 Symbicort 160/4.5mcg

1 148.176,00

148.176

1632 0000116984687 P MOHAMMAD PANJAR

01825 23/03/2016 Novorapid Flexpen 100 UI/ml

3 322.604,10

435.577

1633 0000117091056 P ABDUL KADIR AFANDI,


S.PD

1634 0000117023253 P SUDARJATI S

1635 0000116986713 P SRI ROHANI HAYATI

Allopurinol 300 mg

Lantus Solostar 100 UI/ml

1 107.100,00

23 114.816,00

Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

01831 23/03/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 2 mg

23

12.835,84

Diovan 80 mg

23 114.816,00

Metformin 500 mg

69

9.936,00

01832 23/03/2016 Amlodipine 10 mg

23

9.715,20

23 114.816,00

01830 23/03/2016 Diovan 80 mg

Diovan 80 mg

23

5.873,28

134.467

147.303

124.531

1636 0000774324404 P HASUNAH

01834 23/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1637 0000117130421 P SUPARMAN

01836 23/03/2016 Furosemide 40 mg

23

2.502,40

11.776

23

9.273,60

23

31.648,00

23

12.659,20

01838 23/03/2016 Miniaspi 80 mg

23

4.357,12

Lisinopril 5 mg

23

10.304,00

23 161.920,00

69

9.936,00

23

8.508,16

46

6.624,00

Spironolacton 25 mg
1638 0000116981098 P AKHMAD NAJIRUDIN

01837 23/03/2016 Fenofibrate 100 mg


Glimepiride 4 mg

1639 0000117052817 P NASAR

1640 0000116926637 P ABD.KADIR

01840 23/03/2016 Gliclazide 60 mg


Metformin 500 mg

1641 0000116963684 P SATUAH JD SURI

01841 23/03/2016 Gemfibrozil 300 mg


Metformin 500 mg

Halaman :

122

44.307

14.661

171.856

29.705

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

Propranolol 10 mg

23

1.913,60

Glimepiride 4 mg

23

12.659,20

23

5.873,28

69

7.418,88

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

1644 0000117121285 P SUPRAPTO

01849 23/03/2016 Captopril 50 mg

69

12.364,80

12.365

1645 0000117020744 I SITI HASANAH

01856 23/03/2016 Metformin 500 mg

69

9.936,00

22.595

23

12.659,20

23 161.920,00

Amlodipine 10 mg

23

9.715,20

Fenofibrate 100 mg

23

31.648,00

Metformin 500 mg

69

9.936,00

01864 23/03/2016 Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Isosorbid Dinitrat 5 mg

69

7.772,16

46 164.451,84

12

76.800,00

1642 0000116886126 P MOCH. IKSAN

01842 23/03/2016 Allopurinol 300 mg


Captopril 25 mg

1643 0000777983501 P FAISAL

01843 23/03/2016 Amlodipine 10 mg

Glimepiride 4 mg
1646 0000117047294 I HJ. RUSTINI

1647 0000774575954 P SRI ROFIATUN

1648 0000977368588 S ABRAHAM AJIE

01857 23/03/2016 Gliclazide 60 mg

01866 23/03/2016 Depakote ER 250 mg


Clorilex 100 100 mg

13.292

28.704

213.219

31.118

241.252

1649 0001048449745 P MOH.TOHA

01871 23/03/2016 Propranolol 40 mg

35

4.793,60

4.794

1650 0001328188138 P MOCH.RIDA'I

01875 23/03/2016 Glimepiride 2 mg

23

12.835,84

22.772

Metformin 500 mg

69

9.936,00

1651 0001328189646 P SUNAR HAYATI

01876 23/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1652 0000775334878 P SUBAIDI

01881 23/03/2016 Trifluoperazin 5 mg

23

11.923,20

97.202

Clorilex 100 100 mg

12

76.800,00

Klorpromazin 100 mg

46

8.478,72

23

16.574,72

69

5.740,80

23

8.508,16

8.508

1 142.799,58

486.799

1653 0000775920802 P ROMLAH

01882 23/03/2016 Thyrozol 5 mg


Propranolol 10 mg

1654 0000117126393 I NUR AFLAHA RAFITRIN,S 01884 23/03/2016 Gemfibrozil 300 mg


SOS
1655 0000116949262 I SITI ROCHYATIN
01885 23/03/2016 Seretide Diskus 250 250 mcg/puff

Halaman :

123

22.316

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Glimepiride 3 mg

Novorapid Flexpen 100 UI/ml

Metformin 500 mg

Lantus Solostar 100 UI/ml

23

Harga
Obat

Harga
Diajukan

11.893,76

2 215.069,40
69

9.936,00

1 107.100,00

1656 0000774128632 P KIYEH

01896 24/03/2016 Thyrozol 10 mg

23

33.414,40

33.414

1657 0000149090984 P RIFADI

01897 24/03/2016 Gemfibrozil 300 mg

23

8.508,16

850.080

1658 0000117081876 P MARIA THERESIA


SETYAWATI
1659 0001317289937 P HAIRIYAH

1660 0000775630787 P MUSLIHAH

Novorapid Flexpen 100 UI/ml

4 430.138,80

Micardis 80 mg

23 191.360,00

Allopurinol 300 mg

23

Lantus Solostar 100 UI/ml

2 214.200,00

01900 24/03/2016 Clopidogrel 75 mg

23 100.096,00

100.096

01904 24/03/2016 Lisinopril 5 mg

23

10.304,00

686.726

Novorapid Flexpen 100 UI/ml

Fenofibrate 100 mg

Lantus Solostar 100 UI/ml

01907 24/03/2016 Metformin 500 mg


Glimepiride 4 mg

1661 0000773891076 P ARIYAH

01912 24/03/2016 Amlodipine 10 mg


Bisoprolol 5 mg

1662 0000117070615 P MAIHASANAH

1663 0000117130037 P HERI WIDIASTUTI

1664 0000116931789 P DARSONO

01922 24/03/2016 Apidra Solostar 100 UI/ml

124

5 537.673,50
23

31.648,00

1 107.100,00

69

9.936,00

23

12.659,20

23

9.715,20

23

18.988,80

2 199.495,80

Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

23

4.357,12

Lisinopril 10 mg

23

17.664,00

Isosorbid Dinitrat 5 mg

69

7.772,16

Allopurinol 300 mg

23

5.873,28

Metformin 500 mg

69

9.936,00

23

4.357,12

23

9.715,20

01923 24/03/2016 Miniaspi 80 mg

01924 24/03/2016 Miniaspi 80 mg


Amlodipine 10 mg

Halaman :

5.873,28

22.595

28.704

226.875

45.603

27.718

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Isosorbid Dinitrat 5 mg

69

7.772,16

Allopurinol 300 mg

23

5.873,28

Harga
Diajukan

1665 0000773892494 P KAMARIATUL JANNAH

01925 24/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1666 0000116970647 P UDDIN

01927 24/03/2016 Levopar 125 mg komb

69 132.480,00

132.480

1667 0000776116258 P SUTIYEH

01934 24/03/2016 Miniaspi 80 mg

23

4.357,12

15.967

Lisinopril 5 mg

23

10.304,00

Furosemide 40 mg

12

1.305,60

23 191.360,00

Furosemide 40 mg

23

2.502,40

Metformin 500 mg

69

9.936,00

23

11.893,76

46

6.624,00

46

23.846,40

23

4.239,36

1668 0000206001606 P MOH. SURI

1669 0000116909076 I S U R A T M I

01936 24/03/2016 Micardis 80 mg

01937 24/03/2016 Glimepiride 3 mg


Metformin 500 mg

1670 0000116997401 P SUWANDI

01938 24/03/2016 Trifluoperazin 5 mg


Klorpromazin 100 mg

1671 0001323935346 P SAMIATUN

01944 24/03/2016 Seretide Diskus 250 250 mcg/puff

1672 0000117033221 P ACH. DAILAMI, A.MA

01945 24/03/2016 Lisinopril 10 mg

1673 0001541192319 P FUAD THALIB

01946 24/03/2016 Depakote ER 250 mg


Olandoz 5 5 mg

203.798

18.518

28.086

1 142.799,58

142.800

23

17.664,00

17.664

23

82.225,92

272.114

23 189.888,00

1674 0000775889414 P DUHAN

01948 24/03/2016 Gemfibrozil 300 mg

23

8.508,16

8.508

1675 0000775990506 P HATIB

01957 24/03/2016 Miniaspi 80 mg

23

4.357,12

14.072

23

9.715,20

69

7.772,16

Furosemide 40 mg

12

1.305,60

Concor 2,5 mg

23

21.962,24

Amlodipine 10 mg
1676 0001410231082 P MASKUR

01958 24/03/2016 Isosorbid Dinitrat 5 mg

31.040

1677 0000776141583 P ROHMATUSSOLIHAH

01959 24/03/2016 Risperidon 2 mg

23

29.675,52

29.676

1678 0000774634961 P MAHMUD

01961 24/03/2016 Thyrozol 10 mg

23

33.414,40

39.155

Propranolol 10 mg

69

5.740,80

01962 24/03/2016 Amlodipine 10 mg

23

9.715,20

23 191.360,00

1679 0000116985688 P RIANA TJITRA

Micardis 80 mg

Halaman :

125

201.075

No.

No Ka Peserta

Nama

1680 0000116940396 P JAJUK KUSTIRAHAYU

1681 0000116963717 P SAUDI IDRIS

1682 0000117067059 P SITI DJUHAIRIJAH

No
Rsp

Tgl Pel

Nama Obat

01968 24/03/2016 Miniaspi 80 mg

Jml
R/N Obt

Harga
Obat

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Lisinopril 5 mg

23

10.304,00

01969 24/03/2016 Bisoprolol 5 mg

23

18.988,80

Lisinopril 10 mg

23

17.664,00

Metformin 500 mg

69

9.936,00

Lantus Solostar 100 UI/ml

1 107.100,00

3 322.604,10

Lantus Solostar 100 UI/ml

1 107.100,00

Allopurinol 100 mg

23

01971 24/03/2016 Novorapid Flexpen 100 UI/ml

Harga
Diajukan
42.040

153.689

432.236

2.531,84

1683 0001837221254 P HAMID MANNAN MUNIF

01973 24/03/2016 Harnal Ocas 0,4 mg

23 200.192,00

200.192

1684 0001048325499 P MUZAKKI

01980 24/03/2016 Glimepiride 2 mg

12

6.696,96

6.697

1685 0001383285857 P RUMSIATI

01981 24/03/2016 Glicab 80 mg

46

13.895,68

23.832

69

9.936,00

23

21.962,24

Isosorbid Dinitrat 5 mg

69

7.772,16

Berotec MDI 100 mcg/puff

91.854,00

Metformin 500 mg
1686 0000117124547 P RUKIYATUN
KUSDWITANTY

01982 24/03/2016 Concor 2,5 mg

121.588

1687 0000774435194 P AMAMAH

01983 24/03/2016 Symbicort 80/4.5mcg

1 139.230,00

139.230

1688 0000210891341 I SANIYAH

01987 24/03/2016 Micardis 80 mg

23 191.360,00

191.360

1689 0000116940699 I SUJANI

01996 24/03/2016 Micardis 80 mg

23 191.360,00

212.704

Gemfibrozil 300 mg

23

8.508,16

Glimepiride 2 mg

23

12.835,84

69

9.936,00

23

12.659,20

1690 0000775056936 P JUNAIDAH

02006 24/03/2016 Metformin 500 mg


Glimepiride 4 mg

1691 0000116982134 S SYAIFUL ARIFIN

02007 24/03/2016 Seretide Diskus 100 100 mcg/puff

1692 0000776409873 P ZAINAL ARIFIN

02013 24/03/2016 Gemfibrozil 300 mg

Lisinopril 10 mg
1693 0000776203514 P MOH.SAHA

Halaman :

126

02016 24/03/2016 Amlodipine 10 mg

22.595

1 127.049,58

127.050

23

8.508,16

26.172

23

17.664,00

23

9.715,20

418.647

No.

No Ka Peserta

Nama

1694 0000117094509 P SAUDATUL MAFRUHAH

No
Rsp

Tgl Pel

Nama Obat

2 215.069,40

Micardis 80 mg

23 191.360,00

Furosemide 40 mg

23

69 132.480,00

23 211.968,00

69 132.480,00

23 211.968,00

46

66.828,80

69

5.740,80

46

23.846,40

16

2.191,36

02017 26/03/2016 Levopar 125 mg komb

02018 26/03/2016 Levopar 125 mg komb


Sifrol ER 375 mcg

1696 0000775485966 P ARTINI

02019 26/03/2016 Thyrozol 10 mg


Propranolol 10 mg

1697 0000116997671 P R HERRY TRIATMOKO

02026 26/03/2016 Trifluoperazin 5 mg


Vitamin - B Complex komb

1698 0000117040645 P PADDUS

02043 26/03/2016 Seretide Diskus 250 250 mcg/puff

1699 0000116917176 I MAISINTI

02045 26/03/2016 Glimepiride 4 mg

Captopril 25 mg
Metformin 500 mg
1700 0000774902272 P JUMARIYAH

02048 26/03/2016 Thyrozol 10 mg


Propranolol 10 mg

1701 0000173012725 I MARFU'AH

Harga
Obat

Novorapid Flexpen 100 UI/ml

Sifrol ER 375 mcg


1695 0000116965484 P SJAMSUDIN, BA

Jml
R/N Obt

02052 26/03/2016 Seretide Diskus 250 250 mcg/puff

2.502,40

344.448

72.570

26.038

142.800

23

12.659,20

30.014

69

7.418,88

69

9.936,00

23

33.414,40

23

1.913,60

35.328

1 142.799,58

142.800
90.675

46

88.320,00

23

2.355,20

1703 0000199560194 P HAWARI

23

4.357,12

69

7.772,16

Isosorbid Dinitrat 5 mg

344.448

1 142.799,58

1702 0001280212547 P MOHAMMAD ZAIFULLAH 02053 26/03/2016 Levopar 125 mg komb


ZIN
Aminofilin 200 mg
02055 26/03/2016 Miniaspi 80 mg

Harga
Diajukan

12.129

1704 0000116985047 I SUNARTI

02056 26/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1705 0000165727708 I NOER FADLILLAH

02057 26/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1706 0000116939182 P HJ. SUFIATI

02058 26/03/2016 Gliclazide 60 mg

23 161.920,00

191.875

Amlodipine 10 mg

23

9.715,20

Lisinopril 5 mg

23

10.304,00

Metformin 500 mg

69

9.936,00

23

4.357,12

1707 0001476568686 P SADIEH

Halaman :

127

02066 26/03/2016 Miniaspi 80 mg

3.098.871

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Harga
Obat

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

Novorapid Flexpen 100 UI/ml

4 430.138,80

Lantus Solostar 100 UI/ml

N
N

23 2.463.300,0
0
23
11.893,76

69

9.936,00

23

17.664,00

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

1708 0000116908064 P HOSUSIYAH JD. M. AMIN 02067 26/03/2016 Glimepiride 3 mg


Metformin 500 mg
1709 0000116828943 P ABDULLAH, S.AG

Jml
R/N Obt

02072 26/03/2016 Lisinopril 10 mg

Harga
Diajukan

9.715,20

21.830

40.259

1710 0000116934311 P DRS.MOH.KADIR

02078 26/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1711 0000116954076 P MUNI AH JD. ATMAWI

02079 26/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1712 0001871727805 P MISNATI

02080 26/03/2016 Nopres 20 mg

12

6.635,52

52.415

Merlopam 2 mg

23

39.479,04

Alprazolam 0,5 mg

23

6.300,16

1713 0000116805734 P MOH. SALEH

02086 26/03/2016 Gemfibrozil 300 mg

23

8.508,16

8.508

1714 0000165129039 I ATIRAH

02087 26/03/2016 Gemfibrozil 300 mg

23

8.508,16

8.508

1715 0000976649376 I MAIMUNA

02091 26/03/2016 Novorapid Flexpen 100 UI/ml

4 430.138,80

644.339

2 214.200,00

Lantus Solostar 100 UI/ml


1716 0000774156453 P MUHIR

02092 26/03/2016 Thyrozol 5 mg


Propranolol 10 mg

46

33.149,44

46

3.827,20

1717 0000116976936 I MAIMUNAH

02093 26/03/2016 Lantus Solostar 100 UI/ml

1718 0000195063219 P A. ZAINI ADAPS

02095 26/03/2016 Miniaspi 80 mg

1 107.100,00

107.100

23

4.357,12

12.129

69

7.772,16

46

59.351,04

Depakote ER 250 mg

23

82.225,92

Clorilex 100 100 mg

38.400,00

Isosorbid Dinitrat 5 mg
1719 0001819659925 P MOH.BAHRI

36.977

02096 26/03/2016 Risperidon 2 mg

179.977

1720 0001676182847 P SHALEH

02099 26/03/2016 Avodart 0,5 mg

23 209.024,00

209.024

1721 0000117121522 P LIEN CHAJATI

02100 26/03/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

322.169

1 107.100,00

Lantus Solostar 100 UI/ml

Halaman :

128

No.

No Ka Peserta

Nama

1722 0000117032681 P NANIK SUGIARTI

No
Rsp

Tgl Pel

Nama Obat

02101 26/03/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

1723 0000198517342 I IZZATI

02102 26/03/2016 Glimepiride 3 mg

Jml
R/N Obt

Harga
Obat

2 215.069,40

1 107.100,00

23

11.893,76

Lisinopril 10 mg

23

17.664,00

Metformin 500 mg

69

9.936,00

Harga
Diajukan
322.169

39.494

1724 0000169910627 S RUKSIN

02103 26/03/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

1725 0001895626462 P SUKARLANA

02105 26/03/2016 Merlopam 2 mg

23

39.479,04

52.197

23

12.718,08

23

39.479,04

23

6.300,16

23

39.479,04

Alprazolam 0,5 mg

23

6.300,16

02118 28/03/2016 Amlodipine 10 mg

23

9.715,20

23

27.968,00

Nopres 20 mg
1726 0000116896713 P H.SLAMET,A.MD

02107 26/03/2016 Merlopam 2 mg


Alprazolam 0,5 mg

1727 0000117001732 S BITUNG LUGITO

1728 0000116958802 P R.M.ISKANDAR


MIFTAH,SH

02108 26/03/2016 Merlopam 2 mg

Glikuidon 30 mg

45.779

45.779

37.683

1729 0000116958813 I DRA.AGUSTINA

02119 28/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1730 0000116955911 P NY.R.DJUMAINNA

02120 28/03/2016 Amlodipine 10 mg

23

9.715,20

14.661

46

4.945,92

02140 28/03/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

69

21.638,40

23

3.238,40

Captopril 25 mg
1731 0001410060846 P SRI TARI PUSPA SAFA

1732 0000775092431 P BUNIDAH

02142 28/03/2016 Carbamazepine 200 mg


Vitamin B6 10 mg

14.985

24.877

1733 0001304389405 P NOVITA ADHIYANTI

02143 28/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1734 0000166446213 S MOH. AFFAN

02154 28/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1735 0000117125943 P HARFINI

02155 28/03/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1736 0000209156477 I NUZUL IMAMIYAH

02156 28/03/2016 Gemfibrozil 300 mg

23

8.508,16

21.344

23

12.835,84

Glimepiride 2 mg
1737 0000172349785 1 IRA ANGGRAINI

02162 28/03/2016 Symbicort 80/4.5mcg

1738 0000116849158 P WARIYANTO

02163 28/03/2016 Lisinopril 10 mg

N
N

Amlodipine 5 mg

Halaman :

129

1 139.230,00

139.230

23

17.664,00

35.063

23

5.505,28

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Glimepiride 3 mg

1739 0000776556483 P MUDIAH

02164 28/03/2016 Spironolacton 25 mg


Furosemide 40 mg

Jml
R/N Obt

Harga
Obat

23

11.893,76

23

9.273,60

23

2.502,40

Harga
Diajukan

11.776

1740 0000116706385 P SYAMSUL ARIFIN

02167 28/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1741 0000117059927 P FARIS MUDZAKKIR

02178 28/03/2016 Euthyrox 0,1 mg

23

25.024,00

25.024

1742 0001105656996 P MISLI

02181 28/03/2016 Lisinopril 5 mg

23

10.304,00

40.642

Glimepiride 3 mg

23

11.893,76

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

69

9.936,00

23

12.835,84

46

6.624,00

23

4.357,12

69

7.772,16

1743 0000116986781 P SRI WARNINGSIH

02185 28/03/2016 Glimepiride 2 mg


Metformin 500 mg

1744 0000776314214 P TIPYAN

02186 28/03/2016 Miniaspi 80 mg


Isosorbid Dinitrat 5 mg

19.460

12.129

1745 0000117048767 P MARSUKI

02187 28/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1746 0000774734758 P YASID

02190 28/03/2016 Furosemide 40 mg

326,40

326

1747 0000775225102 P MUHABBAH

02198 28/03/2016 Glimepiride 3 mg

23

11.893,76

21.830

69

9.936,00

Metformin 500 mg
1748 0000780597933 P SAMI

02199 28/03/2016 Lisinopril 10 mg

23

17.664,00

17.664

1749 0000116970906 I SUNAYYA

02200 28/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1750 0000775970638 P KHOIRUL UMAM

02207 28/03/2016 Risperidon 2 mg

23

29.675,52

29.676

1751 0001048546541 P ENDANG WAHYUNI

02208 28/03/2016 Thyrozol 10 mg

46

66.828,80

72.570

69

5.740,80

Propranolol 10 mg
1752 0001048493327 A WARDATUL LAILIYAH

02239 29/03/2016 Thyrozol 10 mg

23

33.414,40

33.414

1753 0000117033614 P SITI RAMLAH

02241 29/03/2016 Glicab 80 mg

46

13.895,68

27.968

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

02242 29/03/2016 Amlodipine 10 mg

23

9.715,20

Glicab 80 mg

46

13.895,68

Furosemide 40 mg

23

2.502,40

1754 0000116939542 P HJ.SITI JASIRAH

Halaman :

130

36.049

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Metformin 500 mg

1755 0000116935986 P H. MOH. EKSAN HS

1756 0000116984709 P MOHAMMAD RIDA`I

Jml
R/N Obt

Harga
Obat

69

9.936,00

46

13.895,68

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Allopurinol 300 mg

23

5.873,28

Metformin 500 mg

69

9.936,00

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

02243 29/03/2016 Glicab 80 mg

02245 29/03/2016 Miniaspi 80 mg

Harga
Diajukan

43.777

33.061

1757 0000117130972 P DIDIK ATRAWI

02261 29/03/2016 Metformin 500 mg

69

9.936,00

9.936

1758 0000117131229 P TOHARI

02262 29/03/2016 Metformin 500 mg

69

9.936,00

143.496

Novomix Flexpen 100 UI/ml


1759 0000117131117 P MOHAMMAD ANSHARI

1760 0000778296137 P NURHAYATI

1761 0001048637463 P FARIDAH

1763 0000774977242 P JUHAIRIYAH

23

1.648,64

Fenofibrate 100 mg

23

31.648,00

Lantus Solostar 100 UI/ml

02267 29/03/2016 Amlodipine 10 mg

23

9.715,20

Captopril 25 mg

69

7.418,88

Lantus Solostar 100 UI/ml

Metformin 500 mg

69

9.936,00

02268 29/03/2016 Propranolol 10 mg

69

5.740,80

46

18.782,72

02269 29/03/2016 Bisoprolol 5 mg

23

18.988,80

Miniaspi 80 mg

23

4.357,12

Ramipril 5 mg

23

17.075,20

Clopidogrel 75 mg

23 100.096,00

Glimepiride 1 mg

23

7.801,60

Metformin 500 mg

69

9.936,00

46

66.828,80

69

5.740,80

02272 29/03/2016 Thyrozol 10 mg

131

140.397

1 107.100,00

Propranolol 10 mg

Halaman :

1 133.560,00

02263 29/03/2016 Glibenklamide 5 mg

Propiltiourasil 100 mg
1762 0000116795799 P ABD RAHMAN

134.170

1 107.100,00

24.524

158.255

72.570

No.

No Ka Peserta

Nama

1764 0001302820929 P QURROTUL AINI

No
Rsp

Tgl Pel

Nama Obat

02273 29/03/2016 Propranolol 10 mg

Harga
Obat

46

3.827,20

23

16.574,72

23

17.664,00

Amlodipine 10 mg

23

9.715,20

Glimepiride 1 mg

23

7.801,60

Thyrozol 5 mg
1765 0000117036821 P TITIN SUMARNI

Jml
R/N Obt

02290 29/03/2016 Lisinopril 10 mg

Harga
Diajukan
20.402

35.181

1766 0000776982339 P SUMA'AH

02291 29/03/2016 Furosemide 40 mg

23

2.502,40

2.502

1767 0000775773764 P JUHAIRIYAH

02309 29/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1768 0001885775962 P KHUSNUL KHATIMAH

02317 29/03/2016 Thyrozol 10 mg

23

33.414,40

35.328

23

1.913,60

23

11.893,76

Metformin 500 mg

69

9.936,00

02326 30/03/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

02327 30/03/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

23 191.360,00

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

1773 0000116980435 1 OCTA ANDRIANIKAPUTRI 02330 30/03/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

10.304,00

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

69 132.480,00

23 211.968,00

12

Propranolol 10 mg
1769 0000116910797 P MENA JD.II
SANGNGARAN

1770 0000116827852 P MOH ZAINI

1771 0000116981188 P AMANIYAH

1772 0001048572663 P SURIMA

1774 0000116945807 P MOCH. SADALI

1775 0000117087085 P PURWANTO

02325 30/03/2016 Glimepiride 3 mg

02329 30/03/2016 Micardis 80 mg

02331 30/03/2016 Lisinopril 5 mg

02354 30/03/2016 Levopar 125 mg komb


Sifrol ER 375 mcg

1776 0000116937595 P HALIMATUS SA'DIYAH

Halaman :

132

02355 30/03/2016 Bisoprolol 5 mg

9.907,20

21.830

31.545

31.545

213.955

14.985

29.852

344.448

21.683

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

Harga
Diajukan

1777 0001410112765 P ZAINULLAH

02357 30/03/2016 Thyrozol 10 mg

46

66.828,80

66.829

1778 0000119231976 P DR. RIJANTO

02358 30/03/2016 Miniaspi 80 mg

23

4.357,12

201.590

Micardis 80 mg

23 191.360,00

Allopurinol 300 mg

23

5.873,28

1779 0000166924416 I SITI AMINA

02366 30/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1780 0001291432138 P SYAMSIYAH

02367 30/03/2016 Miniaspi 80 mg

23

4.357,12

6.860

23

2.502,40

02368 30/03/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

02369 30/03/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

Furosemide 40 mg
1781 0001048465304 P MOH ZUHDI

1782 0000774635387 P MOH ZAINAL AMIN

1783 0000117041231 P M HUSNI ARIFANDI

1784 0001438948585 P ASMANIYA

02370 30/03/2016 Novorapid Flexpen 100 UI/ml

Captopril 50 mg

Lantus Solostar 100 UI/ml

02371 30/03/2016 Amlodipine 5 mg


Candesartan Cilexetil 16 mg

2 215.069,40
69

14.985

14.985

334.534

12.364,80

1 107.100,00

23

23 144.256,00

5.505,28

149.761

1785 0000776623059 P JUMAATI

02372 30/03/2016 Thyrozol 10 mg

23

33.414,40

33.414

1786 0000775128879 P MOTRO

02373 30/03/2016 Stalevo 325 mg komb

69 786.048,00

786.048

1787 0000775058253 P BAHRUD

02388 30/03/2016 Thyrozol 10 mg

23

33.414,40

33.414

1788 0000116984935 P MUNIFAH

02397 30/03/2016 Amlodipine 10 mg

23

9.715,20

9.715

1789 0001384712313 P ANNI IRMAWATI

02401 30/03/2016 Micardis 80 mg

23 191.360,00

191.360

1790 0000116814554 P MOHAMMAD SAHID

02402 30/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1791 0000116987769 P TUNDJIYAH

02411 30/03/2016 Micardis 80 mg

23 191.360,00

197.233

Allopurinol 300 mg

23

5.873,28

1792 0000116980389 P ABDUL MUKTI

02412 30/03/2016 Simvastatin 20 mg

23

11.511,04

11.511

1793 0000774242875 P SEKIYAH

02414 30/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1794 0000116813946 P MOH ABUSALIM

02419 30/03/2016 Novorapid Flexpen 100 UI/ml

3 322.604,10

536.804

Halaman :

133

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Lantus Solostar 100 UI/ml

1795 0000775111364 P SU'ADI

Jml
R/N Obt
N

Harga
Obat

Harga
Diajukan

2 214.200,00

02420 30/03/2016 Miniaspi 80 mg

23

Micardis 80 mg

23 191.360,00

Furosemide 40 mg

46

23 191.360,00

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

1797 0000117105074 P HASAN JAYADI

02422 30/03/2016 Allopurinol 300 mg

23

5.873,28

5.873

1798 0000117049702 P NORHAYATI

02426 30/03/2016 Micardis 80 mg

23 191.360,00

200.008

12

8.647,68

23

9.715,20

69

7.772,16

23

9.715,20

1796 0000773726894 P SYAMSIYAH

02421 30/03/2016 Micardis 80 mg

Thyrozol 5 mg
1799 0000116984103 S SUDARMO

02428 30/03/2016 Amlodipine 10 mg


Isosorbid Dinitrat 5 mg

1800 0000777687153 P HAMIYAH

1801 0001268393242 P FATHORRAHMAN

1802 0000116994813 P MAHMUDAH

02429 30/03/2016 Amlodipine 10 mg

4 430.138,80

Lantus Solostar 100 UI/ml

1 107.100,00

02431 30/03/2016 Furosemide 40 mg

23

2.502,40

Bisoprolol 5 mg

23

18.988,80

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

9.715,20

23

1.648,64

23

3.312,00

23 191.360,00

Novorapid Flexpen 100 UI/ml

6 645.208,20

Concor 2,5 mg

Lantus Solostar 100 UI/ml

2 214.200,00

02432 30/03/2016 Glibenklamide 5 mg

02435 30/03/2016 Micardis 80 mg

23

200.722

5.004,80

Novorapid Flexpen 100 UI/ml

Metformin 500 mg
1803 0001292062871 P UMMI KULSUM

4.357,12

213.955

17.487

546.954

222.566

4.961

1.072.730

21.962,24

1804 0000779796494 P K.ALAWI

02436 30/03/2016 Micardis 80 mg

23 191.360,00

191.360

1805 0000776314855 P HELMIYAH SUNAMI

02438 30/03/2016 Glimepiride 4 mg

23

12.659,20

12.659

1806 0000116983394 S ACH. SYAFI'IE

02443 31/03/2016 Gemfibrozil 300 mg

23

8.508,16

29.219

23

5.505,28

Amlodipine 5 mg

Halaman :

134

No.

No Ka Peserta

Nama

1807 0000049200186 P BAIDAI

No
Rsp

Tgl Pel

Nama Obat

Harga
Obat

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

23

3.312,00

02444 31/03/2016 Amlodipine 10 mg

23

9.715,20

23 114.816,00

23

17.664,00

Vitamin B6 10 mg

16

2.252,80

Phenytoin 100 mg

69

11.746,56

Diovan 80 mg
1808 0000211105282 I HASIJAH

Jml
R/N Obt

02455 31/03/2016 Lisinopril 10 mg

Harga
Diajukan

124.531

31.663

1809 0000116935661 P H. ABDUL MUGID

02465 31/03/2016 Glimepiride 3 mg

517,12

517

1810 0000774541574 P ASMANI

02466 31/03/2016 Glikuidon 30 mg

46

55.936,00

55.936

1811 0001868440252 I KURRATUL AINI

02483 31/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1812 0000116828515 I FARIDATUL JANNAH

02484 31/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1813 0001434124787 P TINIYATUN

02485 31/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1814 0001961140768 P SULAIHA

02493 31/03/2016 Thyrozol 10 mg

46

66.828,80

71.622

35

4.793,60

23

39.479,04

12

76.800,00

Propranolol 40 mg
1815 0001476138486 P MUH MASYKUR

02501 31/03/2016 Merlopam 2 mg


Clorilex 100 100 mg

1816 0001862452844 P MUHAMMAD S.

02503 31/03/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

2 215.069,40

1 107.100,00

116.279

322.169

1817 0000198146992 I SUMARNI

02509 31/03/2016 Furosemide 40 mg

12

1.305,60

1.306

1818 0000117034773 P SITTI HINDUN


RUSMAININAH

02510 31/03/2016 Bisoprolol 5 mg

23

18.988,80

28.925

69

9.936,00

Metformin 500 mg
1819 0000116983719 P KUTSIYAH

02512 31/03/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

3 322.604,10

1 107.100,00

429.704

1820 0000117003969 P SUKARDI

02516 31/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1821 0000116786935 P IMAM SOPHI

02524 31/03/2016 Olandoz 10 10 mg

23 329.728,00

342.063

23

12.335,36

23

33.414,40

23

1.913,60

46

66.828,80

Foransi 10 10 mg
1822 0000777977605 P RIFAIE

02526 31/03/2016 Thyrozol 10 mg


Propranolol 10 mg

1823 0000774684325 P ANDRIYANI

Halaman :

135

02527 31/03/2016 Thyrozol 10 mg

35.328

72.928

No.

No Ka Peserta

Nama

1824 0000117155373 P JUWAIRIYAH

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Furosemide 40 mg

12

1.305,60

Propranolol 40 mg

35

4.793,60

02528 31/03/2016 Furosemide 40 mg

12

1.305,60

Propiltiourasil 100 mg

69

28.174,08

Propranolol 10 mg

69

5.740,80

Harga
Diajukan

35.220

1825 0001126067411 P AHMAD JUFRI SETIAWAN 02534 31/03/2016 Novorapid Flexpen 100 UI/ml
HADI
Lantus Solostar 100 UI/ml

3 322.604,10

1 107.100,00

1826 0001814601194 P SITI MARYAM

02535 31/03/2016 Metformin 500 mg

69

9.936,00

9.936

1827 0002033898614 P MISTARI

02536 31/03/2016 Miniaspi 80 mg

23

4.357,12

227.935

Gemfibrozil 300 mg

23

8.508,16

Novorapid Flexpen 100 UI/ml

1828 0001410416177 P FATHOR RAHMAN

1829 0000117008403 I SITTI AISYAH

1830 0000116790693 2 DEWI NOERFADYLAH

1831 0000116993621 P HOZAIMAH

2 215.069,40

02537 31/03/2016 Trifluoperazin 5 mg

46

23.846,40

Clorilex 100 100 mg

12

76.800,00

02540 31/03/2016 Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

Akarbose 100 mg

46

58.291,20

46

14.425,60

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

12.659,20

23

4.975,36

02546 31/03/2016 Carbamazepine 200 mg

02548 31/03/2016 Glimepiride 4 mg


Simvastatin 10 mg

429.704

100.646

90.602

29.411

17.635

1832 0000195979307 I HJ. HERLINAWATI

02549 31/03/2016 Glimepiride 3 mg

23

11.893,76

11.894

1833 0000774629357 P SUAMI

02551 31/03/2016 Gemfibrozil 300 mg

23

8.508,16

27.816

Miniaspi 80 mg

23

4.357,12

Furosemide 40 mg

12

1.305,60

Allopurinol 300 mg

23

5.873,28

Isosorbid Dinitrat 5 mg

69

7.772,16

1834 0001305129363 P NAILI

Halaman :

136

02554 31/03/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

No.

No Ka Peserta

Nama

1835 0000109714476 P INA SUPARSI

No
Rsp

Tgl Pel

Nama Obat

02555 31/03/2016 Amlodipine 10 mg

Jml
R/N Obt

Harga
Obat

23

Diovan 80 mg

23 114.816,00

1836 0001138508818 P CAHYO BUDIONO

00008 01/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1837 0001048355021 P ARYANI

00018 01/04/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

1838 0000116983607 P JUNAIDI

00022 01/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1839 0000196300912 I IDA FARIDA YUNAIDI

00023 01/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1840 0000116986961 P SUHAMIYATI

00035 01/04/2016 Diovan 80 mg

23 114.816,00

114.816

1841 0001048814482 P SUNARIS

00036 01/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1842 0000116985734 P RIFATUN

00039 01/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1843 0001901994625 P YUDI EKO SARI

00040 01/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1844 0000776109159 P HAKIMAH

00064 02/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1845 0000117008436 P RISKIYAH

00065 02/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1846 0000116980402 P ABDUL WAHED

00068 02/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1847 0000116981313 P ARSIDI

00077 02/04/2016 Amlodipine 10 mg

23

9.715,20

18.223

23

8.508,16

46

66.828,80

Lisinopril 5 mg

23

10.304,00

Propranolol 10 mg

46

3.827,20

Gemfibrozil 300 mg
1848 0002041595627 P WASIT

00082 02/04/2016 Thyrozol 10 mg

9.715,20

Harga
Diajukan
124.531

80.960

1849 0000775254475 P HAMIDAH

00084 02/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

1850 0000116896195 P CHAIRUNNISA

00088 02/04/2016 Amlodipine 10 mg

23

9.715,20

27.379

23

17.664,00

Lisinopril 10 mg
1851 0001048518292 P TITIK WAHYUNI

00090 02/04/2016 Glimepiride 3 mg

23

11.893,76

11.894

1852 0001048547261 P MAIMUNA

00095 02/04/2016 Glimepiride 3 mg

23

11.893,76

21.830

Metformin 500 mg

69

9.936,00

00096 02/04/2016 Amlodipine 10 mg

23

9.715,20

1853 0000117080065 P BUSTAMI

1854 0001855961673 P INSUL ARIF

Novorapid Flexpen 100 UI/ml

4 430.138,80

Lantus Solostar 100 UI/ml

3 321.300,00

00098 02/04/2016 Clorilex 100 100 mg


Risperidon 2 mg

Halaman :

137

12

76.800,00

46

59.351,04

761.154

136.151

No.

No Ka Peserta

Nama

1855 0000774580397 P MAHSUNAH

No
Rsp

Tgl Pel

Nama Obat

00099 02/04/2016 Thyrozol 10 mg

1857 0000166164917 P ANDYKA BUDIHARTO

1858 0000116945032 P MISRIANI

23

33.414,40

46

3.827,20

23

11.893,76

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

Fenofibrate 100 mg

23

31.648,00

12

20.597,76

Clorilex 100 100 mg

12

76.800,00

Risperidon 2 mg

46

59.351,04

23

16.574,72

69

5.740,80

46

14.425,60

R.01 11,5

17.664,00

00105 02/04/2016 Glimepiride 3 mg

00106 02/04/2016 Merlopam 2 mg

00107 02/04/2016 Thyrozol 5 mg


Propranolol 10 mg

1859 0001295679982 P HAIKAL BARIO

Harga
Obat

Propranolol 10 mg
1856 0001845099123 P DURRIYAH

Jml
R/N Obt

00115 02/04/2016 Carbamazepine 200 mg


Risperidon 1 mg

Harga
Diajukan
37.242

67.550

156.749

22.316

32.090

1860 0002048467792 P MARIDAH

00117 02/04/2016 Glimepiride 3 mg

23

11.893,76

11.894

1861 0000166411901 I ROFIQAH

00118 02/04/2016 Propranolol 10 mg

46

3.827,20

20.402

23

16.574,72

23 147.200,00

Klorpromazin 100 mg

46

8.478,72

Haloperidol 5 mg

23

2.826,24

23

9.273,60

Isosorbid Dinitrat 5 mg

46

5.181,44

Furosemide 40 mg

23

2.502,40

Candesartan Cilexetil 8 mg

23

91.264,00

Clopidogrel 75 mg

23 100.096,00

00138 04/04/2016 Furosemide 40 mg

23

2.502,40

23

91.264,00

00139 04/04/2016 Furosemide 40 mg

23

2.502,40

Amlodipine 10 mg

23

9.715,20

Thyrozol 5 mg
1862 0001895351286 P MOH.HASAN

1863 0001078173944 S AKHMAD EFFENDI

1864 0001085741199 P SITI SUNARTI

00121 02/04/2016 Clorilex 100 100 mg

00136 04/04/2016 Spironolacton 25 mg

Candesartan Cilexetil 8 mg
1865 0001321097319 P ABDUL HOLID

Halaman :

138

158.505

208.317

93.766

155.590

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

Dopamet 250 mg

69

70.656,00

Irbesartan 300 mg

23

72.716,80

1866 0001260878646 P H.MAWARDI

00140 04/04/2016 Furosemide 40 mg

23

2.502,40

2.502

1867 0000116903046 P ACH.MUTTAQI, BA

00141 04/04/2016 Glimepiride 4 mg

23

12.659,20

22.595

69

9.936,00

23

8.508,16

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg
1868 0000195133847 S BUDI SUDIYANTO

00147 04/04/2016 Gemfibrozil 300 mg

31.103

1869 0000116970344 P TIEN FAISAL

00148 04/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

1870 0000116812991 P FAIZ BIN FAISAL

00149 04/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

1871 0001443194379 P TIHANA

00163 04/04/2016 Furosemide 40 mg

23

2.502,40

23.905

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Miniaspi 80 mg

23

4.357,12

00164 04/04/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

4.357,12

Lisinopril 10 mg

23

17.664,00

Bisoprolol 5 mg

23

18.988,80

Clopidogrel 75 mg

23 100.096,00

2 215.069,40

1 107.100,00

1872 0000116796159 P DHARMA KRISTYANTO

1873 0000117035559 P MASODAH

1874 0000775235182 P ROMILAH

00165 04/04/2016 Miniaspi 80 mg

00166 04/04/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

1875 0000167005359 I NURHAYATI

1876 0001316891237 P SYARIFAH

00167 04/04/2016 Lisinopril 10 mg

23

17.664,00

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

23

17.664,00

23

5.505,28

23 209.024,00

23 170.752,00

00168 04/04/2016 Lisinopril 10 mg


Amlodipine 5 mg

1877 0000116621695 P SURIJANTO

00172 04/04/2016 Avodart 0,5 mg


Harnal D 0,2 mg

Halaman :

139

14.985

141.106

322.169

31.736

23.169

379.776

No.

No Ka Peserta

Nama

1878 0001048464347 P JUANI

1879 0000117059231 P NURULLAH

No
Rsp

Tgl Pel

Nama Obat

00173 04/04/2016 Amlodipine 10 mg

Jml
R/N Obt

Harga
Obat

23

9.715,20

Levopar 125 mg komb

46

88.320,00

Bisoprolol 5 mg

23

18.988,80

Gemfibrozil 300 mg

23

8.508,16

Harga
Diajukan
125.532

00174 04/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1880 0001082303627 P JAMIATUS SAULISTIANA 00175 04/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1881 0001082303403 P SULISTYOWATI

00176 04/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1882 0000774451361 P MARSUNAH

00184 04/04/2016 Thyrozol 10 mg

23

33.414,40

39.155

69

5.740,80

Propranolol 10 mg
1883 0001048564181 P RUKMAH

00185 04/04/2016 Captopril 25 mg

69

7.418,88

7.419

1884 0000775217057 P SITI TIBAH

00186 04/04/2016 Lisinopril 10 mg

23

17.664,00

29.882

Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

1885 0000116981199 P AMINA

00188 04/04/2016 Amlodipine 5 mg

23

5.505,28

5.505

1886 0001048401685 P HAMSIYAH

00196 04/04/2016 Thyrozol 10 mg

46

66.828,80

72.570

69

5.740,80

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

23

11.893,76

23

10.304,00

46

3.827,20

12

8.647,68

23

9.273,60

Furosemide 40 mg

23

2.502,40

Captopril 12,5 mg

69

5.475,84

Propranolol 10 mg
1887 0000117005174 P FAHRUDIN RASYIDI,
S.PD

1888 0000116906005 P DULPAKMIN

00213 04/04/2016 Miniaspi 80 mg

00218 04/04/2016 Glimepiride 3 mg


Lisinopril 5 mg

1889 0001451727753 P FALALAH

00219 04/04/2016 Propranolol 10 mg


Thyrozol 5 mg

1890 0000116627938 P MOH. FADLI

00223 04/04/2016 Spironolacton 25 mg

14.632

22.198

12.475

17.252

1891 0001048775635 P SUCI

00227 04/04/2016 Glikuidon 30 mg

23

27.968,00

27.968

1892 0000774799222 P SANITO

00229 04/04/2016 Miniaspi 80 mg

23

4.357,12

23.905

23

9.273,60

Spironolacton 25 mg

Halaman :

140

No.

No Ka Peserta

Nama

1893 0000774458831 P LUKMAN HAKIM

1894 0001282612871 P TONA

1895 0000098253459 P SUATUN

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

23

7.212,80

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

00237 04/04/2016 Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

00239 04/04/2016 Gliclazide 60 mg

23 161.920,00

Amlodipine 10 mg

23

9.715,20

Allopurinol 100 mg

23

2.531,84

Metformin 500 mg

69

9.936,00

Simvastatin 10 mg

23

4.975,36

00233 04/04/2016 Carbamazepine 200 mg

Harga
Diajukan

22.198

27.379

189.078

1896 0000117044616 P MOHAMAD RIFAI

00242 04/04/2016 Glimepiride 4 mg

23

12.659,20

12.659

1897 0000777728834 P IDA WATI

00252 05/04/2016 Vitamin B6 10 mg

23

3.238,40

14.985

Phenytoin 100 mg

69

11.746,56

69

21.638,40

16

2.252,80

69

7.507,20

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

9.715,20

23

27.968,00

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

46

13.895,68

69

9.936,00

00277 05/04/2016 Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Isosorbid Dinitrat 5 mg

69

7.772,16

1898 0001048545922 P FERI ANGGA RIAWAN

00264 05/04/2016 Carbamazepine 200 mg


Vitamin B6 10 mg

1899 0001439116694 P SUHARINI

1900 0000779286407 P SAPRAWI

1901 0000116906613 I SUPATYA

00266 05/04/2016 Furosemide 40 mg

00267 05/04/2016 Glikuidon 30 mg

00276 05/04/2016 Glicab 80 mg


Metformin 500 mg

1902 0001868602522 P MUHDAR ABDULLAH

Halaman :

141

23.891

208.582

231.546

23.832

131.214

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Clopidogrel 75 mg

Jml
R/N Obt

Harga
Obat

23 100.096,00

Harga
Diajukan

1903 0000116952423 I ZABIDAH

00280 05/04/2016 Glimepiride 2 mg

23

12.835,84

12.836

1904 0000117074362 P CHAIRUL SALEH ARIFIN

00284 05/04/2016 Micardis 80 mg

23 191.360,00

204.196

23

12.835,84

Glimepiride 2 mg
1905 0000116833926 I HOZAIMAH

00285 05/04/2016 Captopril 25 mg

69

7.418,88

7.419

1906 0001048326377 P HOZAIMAH

00291 05/04/2016 Micardis 80 mg

23 191.360,00

191.360

1907 0000100712608 P M FAUZI HOSNI

00303 05/04/2016 Micardis 80 mg

23 191.360,00

191.360

1908 0001473917679 P FATAH HIDAYAT

00304 05/04/2016 Novorapid Flexpen 100 UI/ml

1 107.534,70

298.895

23 191.360,00

00313 05/04/2016 Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

Glimepiride 1 mg

23

7.801,60

Captopril 25 mg

69

7.418,88

23

10.304,00

23

12.659,20

Micardis 80 mg
1909 0001893272815 P ROMLI

1910 0000773652958 P MONARI

00315 05/04/2016 Lisinopril 5 mg


Glimepiride 4 mg

27.438

22.963

1911 0000198517465 2 MUSYARROFAH

00317 05/04/2016 Haloperidol 0,5 mg

46

3.473,92

3.474

1912 0001717473104 P NASIDEH

00318 05/04/2016 Furosemide 40 mg

46

5.004,80

421.149

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

Novorapid Flexpen 100 UI/ml

1913 0000173117665 I RISKIATIN

1914 0000116895734 P ABDURACHMAN

1915 0001312556949 P IMYANI

00320 05/04/2016 Glimepiride 3 mg

142

2 215.069,40

23

11.893,76

Lisinopril 5 mg

23

10.304,00

Metformin 500 mg

46

6.624,00

00321 05/04/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

Furosemide 40 mg

23

2.502,40

Metformin 500 mg

69

9.936,00

Lantus Solostar 100 UI/ml

00332 05/04/2016 Isosorbid Dinitrat 5 mg


Lisinopril 5 mg

Halaman :

9.715,20

28.822

334.608

1 107.100,00

69

7.772,16

23

10.304,00

43.601

No.

No Ka Peserta

Nama

1916 0000117282745 P DJUMAATIYAH JD SAIDI

1917 0000117026302 P HUZAIMAH

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Miniaspi 80 mg

23

4.357,12

Gemfibrozil 300 mg

23

8.508,16

Glimepiride 4 mg

23

12.659,20

23 161.920,00

Miniaspi 80 mg

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Metformin 500 mg

69

9.936,00

Captopril 25 mg

69

7.418,88

23

10.304,00

Fenofibrate 100 mg

23

31.648,00

Glimepiride 4 mg

23

12.659,20

00334 05/04/2016 Gliclazide 60 mg

00336 05/04/2016 Lisinopril 5 mg

1918 0001811575416 P M.ATMO

00337 05/04/2016 Novorapid Flexpen 100 UI/ml

1919 0000776511663 P ABD KADIR

00338 05/04/2016 Glimepiride 4 mg

1920 0001133980514 P SUHARTO

00345 05/04/2016 Glimepiride 4 mg

1921 0000116841767 P SRI HARTINI


1922 0001082445546 P SRIYATI

Harga
Diajukan

191.404

54.611

2 215.069,40

215.069

23

12.659,20

12.659

23

12.659,20

12.659

00348 05/04/2016 Miniaspi 80 mg

23

4.357,12

4.357

00374 06/04/2016 Miniaspi 80 mg

23

4.357,12

24.936

Lisinopril 5 mg

23

10.304,00

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

1923 0000173684169 I DURRIYATUL MILLAH,


S.AG. M.PD
1924 0000116985475 P R HALIFAH

00387 06/04/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

00398 06/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1925 0000117042298 P SRI HARTATI NY

00401 06/04/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

513.529

Micardis 80 mg

23 191.360,00

Lantus Solostar 100 UI/ml

1 107.100,00

23 191.360,00

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

00406 06/04/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

1926 0000773996837 P SUNARYA

1927 0000774275927 P SANIRAH

00405 06/04/2016 Micardis 80 mg

Glimepiride 4 mg

Halaman :

143

213.190

22.595

No.

No Ka Peserta

Nama

1928 0001410103822 P HAMIDAH

No
Rsp

Tgl Pel

Nama Obat

00410 06/04/2016 Glibenklamide 5 mg


Metformin 500 mg

1929 0001048519427 P BUSANI

1930 0001623210309 P SITI ROFIAH

00411 06/04/2016 Novorapid Flexpen 100 UI/ml

Jml
R/N Obt

Harga
Obat

23

1.648,64

69

9.936,00

2 215.069,40

220.015

46

4.945,92

00413 06/04/2016 Captopril 25 mg

46

4.945,92

46

6.624,00
7.914.200

16.163

1931 0000780212463 P ACH.SAUKI

00415 06/04/2016 Top Up Hemofilia RS B Reg I NULL

1932 0000776217712 P DULLA

00420 06/04/2016 Thyrozol 10 mg

1 7.914.200,0
0
46
66.828,80

1933 0000775041175 P MOH.TABRANI

00423 06/04/2016 Trifluoperazin 5 mg

23

11.923,20

23

4.239,36

12

5.376,00

23

2.502,40

23 200.192,00

23 209.024,00

Klorpromazin 100 mg
00426 06/04/2016 Lisinopril 5 mg
Furosemide 40 mg
1935 0000116896094 P BAIDAI

11.585

Captopril 25 mg

Metformin 500 mg

1934 0000172885432 2 SHELY FAIQOTUR


RAUDAH

Harga
Diajukan

00428 06/04/2016 Harnal Ocas 0,4 mg


Avodart 0,5 mg

11.570

66.829

7.878

409.216

1936 0000773638391 P KADIR

00430 06/04/2016 Symbicort 160/4.5mcg

1 148.176,00

148.176

1937 0000117011946 P RAHAYU SUSILAWATI

00433 06/04/2016 Novorapid Flexpen 100 UI/ml

3 322.604,10

575.871

Captopril 25 mg

69

7.418,88

Fenofibrate 100 mg

23

31.648,00

Lantus Solostar 100 UI/ml

2 214.200,00

1938 0000195322397 I MARIYA

00434 06/04/2016 Glimepiride 3 mg

23

11.893,76

11.894

1939 0001432117348 P SALANI

00442 06/04/2016 Allopurinol 300 mg

23

5.873,28

328.043

1940 0000116973213 P MOH. SUKRI

1941 0001379620708 P SILVANA TANI

Novorapid Flexpen 100 UI/ml

2 215.069,40

Lantus Solostar 100 UI/ml

1 107.100,00

23 161.920,00

Miniaspi 80 mg

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Metformin 500 mg

69

9.936,00

23

8.508,16

23

12.659,20

00443 06/04/2016 Gliclazide 60 mg

00444 06/04/2016 Gemfibrozil 300 mg


Glimepiride 4 mg

Halaman :

144

183.985

21.167

No.

No Ka Peserta

Nama

1942 0000117025841 P FATHOR ARIFIN

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

00446 06/04/2016 Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

Candesartan Cilexetil 16 mg

23 144.256,00

Harga
Diajukan
156.474

1943 0001410298525 P NURUL HASANAH

00452 06/04/2016 Captopril 25 mg

69

7.418,88

7.419

1944 0000117397089 I UMIYATI

00453 06/04/2016 Lisinopril 10 mg

23

17.664,00

101.180

Glimepiride 3 mg

23

11.893,76

Thyrozol 10 mg

46

66.828,80

Propranolol 40 mg

35

4.793,60

1945 0000774390442 P ST.RAHMA

00458 06/04/2016 Micardis 80 mg

23 191.360,00

191.360

1946 0000117021082 P ABDUL MAHWAR

00460 06/04/2016 Miniaspi 80 mg

23

4.357,12

13.435

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

1947 0000116985284 I SAMSITI

00464 06/04/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

1948 0000975930085 I SUNARTI

1949 0000116946145 P MOELJADI

1950 0000779511464 P SUGIANTO

1951 0000116958341 P R.ACH.MASJKUR KAMIL

Halaman :

145

INT 06/04/2016 Glimepiride 3 mg

2 215.069,40

1 107.100,00

23

11.893,76

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

69

9.936,00

00470 07/04/2016 Amlodipine 10 mg

23

9.715,20

Miniaspi 80 mg

23

4.357,12

Micardis 80 mg

23 191.360,00

Furosemide 40 mg

23

2.502,40

23

4.357,12

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

00471 07/04/2016 Miniaspi 80 mg

00474 07/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

Digoksin 0,25 mg

23

2.855,68

Furosemide 40 mg

23

2.502,40

Metformin 500 mg

69

9.936,00

Glibenklamide 5 mg

23

1.648,64

322.169

30.338

207.935

16.133

191.390

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Fenofibrate 100 mg

Jml
R/N Obt

Harga
Obat

23

31.648,00

Harga
Diajukan

1952 0000117050062 P MOH SJAIFUL EFENDI

00494 07/04/2016 Glimepiride 4 mg

23

12.659,20

12.659

1953 0001298658543 P SUMNA

00495 07/04/2016 Glimepiride 4 mg

23

12.659,20

22.595

Metformin 500 mg

69

9.936,00

00501 07/04/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

8.508,16

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

1954 0000770165875 P SAFI UDDIN

1955 0000117142751 P MOCHAMAD RUSLI

00502 07/04/2016 Gemfibrozil 300 mg

14.985

31.103

1956 0000199058793 S MOHAMMAD ALI MAKKI

00503 07/04/2016 Phenytoin 100 mg

69

11.746,56

11.747

1957 0000116675752 P MUKTIYAH

00504 07/04/2016 Miniaspi 80 mg

23

4.357,12

570.300

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Novorapid Flexpen 100 UI/ml

4 430.138,80

Lantus Solostar 100 UI/ml

1 107.100,00

1958 0000781432839 P ZAINIYAH

1959 0001390264694 P MARYANI

00505 07/04/2016 Bisoprolol 5 mg

23

18.988,80

Isosorbid Dinitrat 5 mg

69

7.772,16

Captopril 50 mg

69

12.364,80

23 191.360,00

23

12.659,20

00507 07/04/2016 Micardis 80 mg


Glimepiride 4 mg

39.126

204.019

1960 0000116959217 I MISRIATUN

00508 07/04/2016 Thyrozol 10 mg

23

33.414,40

33.414

1961 0000117071087 P RUDY SETIAWAN

00509 07/04/2016 Trifluoperazin 5 mg

23

11.923,20

48.458

Risperidon 2 mg

23

29.675,52

Alprazolam 1 mg

23

6.859,52

23

39.479,04

Alprazolam 1 mg

23

6.859,52

Trifluoperazin 5 mg

23

11.923,20

00511 07/04/2016 Clorilex 100 100 mg

12

76.800,00

23

4.239,36

1962 0000202346032 P SAKDIJAH

1963 0000116673221 P SITI KIPIYAH

00510 07/04/2016 Merlopam 2 mg

Klorpromazin 100 mg

Halaman :

146

58.262

81.039

No.

No Ka Peserta

Nama

1964 0000203023361 I SANIMAH

1965 0000116830552 P DRS. SANUM MA'MUN,


M.PD.I

1966 0000116798049 P MULYADI

No
Rsp

Tgl Pel

Nama Obat

00512 07/04/2016 Micardis 80 mg

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

23 191.360,00

Glimepiride 3 mg

23

11.893,76

Gemfibrozil 300 mg

23

8.508,16

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Diovan 80 mg

23 114.816,00

Clopidogrel 75 mg

23 100.096,00

23

39.479,04

Alprazolam 1 mg

23

6.859,52

Olandoz 5 5 mg

23 189.888,00
1 142.799,58

142.800
10.255

00518 07/04/2016 Miniaspi 80 mg

00519 07/04/2016 Merlopam 2 mg

1967 0000116986342 P SITI NURHAYATI

00522 07/04/2016 Seretide Diskus 250 250 mcg/puff

1968 0000774841061 P HALIMA

00523 07/04/2016 Haloperidol 0,5 mg

46

3.473,92

Alprazolam 0,5 mg

19

5.204,48

Amitriptyline 25 mg

11

1.576,96

211.762

228.984

236.227

1969 0001339414413 P ATNA

00527 07/04/2016 Furosemide 40 mg

11

1.196,80

1.197

1970 0000116998615 P MOCH NAWAWI

00530 07/04/2016 Furosemide 40 mg

23

2.502,40

20.740

Allopurinol 300 mg

23

5.873,28

Captopril 50 mg

69

12.364,80

23

5.873,28

Glimepiride 1 mg

23

7.801,60

Simvastatin 10 mg

23

4.975,36

69

7.418,88

7.419

1 142.799,58

174.153

1971 0000116740348 P ABD SYAKUR

00538 07/04/2016 Allopurinol 300 mg

1972 0001410230744 P TIJA

00539 07/04/2016 Captopril 25 mg

1973 0000775787883 P ABD.AZIZ

00544 07/04/2016 Seretide Diskus 250 250 mcg/puff

Bisoprolol 5 mg

23

18.988,80

Captopril 50 mg

69

12.364,80

18.650

1974 0000774390442 P ST.RAHMA

00557 07/04/2016 Gemfibrozil 300 mg

23

8.508,16

8.508

1975 0001787915316 P SUPARLAN

00559 07/04/2016 Trifluoperazin 5 mg

46

23.846,40

28.086

23

4.239,36

23 191.360,00

Klorpromazin 100 mg
1976 0000116628974 P ZAINIYAH JD. M. ALI
MAS'UD

Halaman :

147

00563 07/04/2016 Micardis 80 mg

191.360

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

1977 0001443797291 P MUTMAINNAH

00571 07/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

1978 0001481131113 P SUBROTO

00573 07/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

1979 0001410151026 P HASUNAH

00576 08/04/2016 Miniaspi 80 mg

23

4.357,12

132.303

Isosorbid Dinitrat 5 mg

69

7.772,16

Clopidogrel 75 mg

23 100.096,00

Captopril 25 mg

69

7.418,88

Glimepiride 4 mg

23

12.659,20

00595 08/04/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

33.414,40

33.414

1 142.799,58

142.800
295.086

1980 0001801424766 P NOVA RISKIYAH

14.985

1981 0001048624018 P ZAINULLAH

00603 08/04/2016 Thyrozol 10 mg

1982 0000166411901 I ROFIQAH

00607 08/04/2016 Seretide Diskus 250 250 mcg/puff

1983 0000117130983 P HAIRUL SALEH

00613 08/04/2016 Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

Lantus Solostar 100 UI/ml

Akarbose 100 mg

46

58.291,20

1984 0000116911405 I RA. ERNANI

00618 08/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

1985 0000774736997 P SI'A

00619 09/04/2016 Metformin 500 mg

69

9.936,00

34.960

Glimepiride 4 mg

23

12.659,20

Captopril 50 mg

69

12.364,80

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Captopril 25 mg

69

7.418,88

1986 0001048397398 P HOLLA

00620 09/04/2016 Miniaspi 80 mg

2 214.200,00

19.548

1987 0000116988502 I SUTAN TINAH

00631 09/04/2016 Metformin 500 mg

69

9.936,00

9.936

1988 0001048544109 P NUR AZIZEH

00638 09/04/2016 Vitamin B6 10 mg

16

2.252,80

13.999

Phenytoin 100 mg

69

11.746,56

1989 0000117061929 P SAHUR RACHMAN

00655 09/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1990 0000116984103 S SUDARMO

00659 09/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

1991 0001298115224 P SATRIA DHARMAWAN


SYAH
1992 0000117090044 I ERMA MEGAWATI

00665 09/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

00666 09/04/2016 Thyrozol 10 mg

66.828,80

68.742

Halaman :

148

46

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Propranolol 10 mg

1993 0000116938967 P HJ. HASIRAH

00668 09/04/2016 Lisinopril 10 mg


Gemfibrozil 300 mg

1994 0001268418677 P SUHAIRIYAH

00669 09/04/2016 Glimepiride 4 mg


Metformin 500 mg

Jml
R/N Obt

Harga
Obat

23

1.913,60

23

17.664,00

23

8.508,16

23

12.659,20

69

9.936,00

Harga
Diajukan

26.172

22.595

1995 0000116970311 P THAIB

00670 09/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

1996 0000116908255 P ISHAK

00672 09/04/2016 Glimepiride 3 mg

23

11.893,76

21.830

69

9.936,00

Metformin 500 mg
1997 0001662375993 P SITI MUFTIRAH

00673 09/04/2016 Glimepiride 3 mg

23

11.893,76

11.894

1998 0000116848844 P MIFTAHOL ARIFIN, SH,


MM

00675 09/04/2016 Amlodipine 10 mg

23

9.715,20

331.885

Novorapid Flexpen 100 UI/ml

2 215.069,40

Lantus Solostar 100 UI/ml

1 107.100,00

1999 0001106407596 P SISILIA KLIANI

00677 09/04/2016 Olandoz 5 5 mg

23 189.888,00

189.888

2000 0001662375982 P MOH.SYAFIUDIN

00678 09/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

2001 0001410239542 P SANUKI

00679 09/04/2016 Miniaspi 80 mg

23

4.357,12

14.632

Furosemide 40 mg

23

2.502,40

Isosorbid Dinitrat 5 mg

69

7.772,16

69

9.936,00

Glimepiride 4 mg

23

12.659,20

00681 09/04/2016 Glimepiride 3 mg

23

11.893,76

69

9.936,00

23

4.357,12

Lisinopril 10 mg

23

17.664,00

Allopurinol 100 mg

23

2.531,84

Lantus Solostar 100 UI/ml

Furosemide 40 mg

46

5.004,80

23

9.273,60

35

4.793,60

23

4.357,12

2002 0000775311671 P SUSMIYATI

2003 0000775105356 P MISBAH

00680 09/04/2016 Metformin 500 mg

Metformin 500 mg
2004 0000099722092 P KASMAN

2005 0001326845114 P MUHARROM

00683 09/04/2016 Miniaspi 80 mg

00686 09/04/2016 Spironolacton 25 mg


Propranolol 40 mg

2006 0000772773186 P SUTIKNO

Halaman :

149

00696 11/04/2016 Miniaspi 80 mg

22.595

21.830

136.658

1 107.100,00

14.067

32.884

No.

No Ka Peserta

Nama

2007 0001385196142 P TEDI RIAN HANDIKA

2008 0001453212156 P FAISOL

2009 0000117056812 1 RAMZAN BARID

2010 0000117022206 I SUYATI

No
Rsp

Tgl Pel

Nama Obat

2012 0001834273956 P ABD.JANNANI

2013 0002042259491 P ZEJI

23

9.715,20

Gemfibrozil 300 mg

23

8.508,16

Lisinopril 5 mg

23

10.304,00

00698 11/04/2016 Vitamin B6 10 mg

16

2.252,80

Phenytoin 100 mg

69

11.746,56

23

9.273,60

Furosemide 40 mg

23

2.502,40

Amlodipine 5 mg

23

5.505,28

46

14.425,60

Olandoz 10 10 mg

23 329.728,00

00708 11/04/2016 Amlodipine 10 mg

23

00701 11/04/2016 Spironolacton 25 mg

00703 11/04/2016 Carbamazepine 200 mg

9.715,20

23

17.664,00

Bisoprolol 5 mg

12

9.907,20

00715 11/04/2016 Miniaspi 80 mg

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Spironolacton 25 mg

23

9.273,60

00717 11/04/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

00719 11/04/2016 Seretide Diskus 250 250 mcg/puff

2015 0001048661291 P WAHYUDI APRIZAL

00725 11/04/2016 Vitamin B6 10 mg

Phenytoin 100 mg
00727 11/04/2016 Spironolacton 25 mg
Furosemide 40 mg

Harga
Diajukan

13.999

17.281

344.154

152.515

1 142.799,58

00714 11/04/2016 Lisinopril 10 mg

2014 0001297237724 P MOH.ZAINI IHKSAN

2016 0000775659778 P jiat

Harga
Obat

Amlodipine 10 mg

Seretide Diskus 250 250 mcg/puff


2011 0000116966035 P SOEGI PRABOWO

Jml
R/N Obt

27.571

23.905

14.985

1 142.799,58

142.800

23

3.238,40

14.985

69

11.746,56

23

9.273,60

12

1.305,60

10.579

2017 0000776136789 P NURIL LAILIN

00730 11/04/2016 Fenofibrate 100 mg

23

31.648,00

31.648

2018 0000203414905 I SITI HOSNIYAH

00737 11/04/2016 Amlodipine 10 mg

23

9.715,20

80.857

Glimepiride 3 mg

23

11.893,76

Lisinopril 10 mg

23

17.664,00

Halaman :

150

No.

No Ka Peserta

Nama

2019 0000117030497 P NAHDIYAH

2020 0000774438399 P SAHERI

No
Rsp

Tgl Pel

Nama Obat

2022 0000114179962 P ABD. KAHIR

Harga
Obat

Fenofibrate 100 mg

23

31.648,00

Metformin 500 mg

69

9.936,00

00746 11/04/2016 Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

00750 11/04/2016 Thyrozol 10 mg

23

33.414,40

69

5.740,80

23

9.273,60

Furosemide 40 mg

23

2.502,40

00752 11/04/2016 Metformin 500 mg

69

9.936,00

23

12.835,84

Propranolol 10 mg
2021 0001436930831 P MAIMUNAH

Jml
R/N Obt

00751 11/04/2016 Spironolacton 25 mg

Glimepiride 2 mg
2023 0001048404881 P SAYYUS

00754 11/04/2016 Spiriva Combo 18 mcg

2024 0001102272219 P SUDARTO

00765 11/04/2016 Isosorbid Dinitrat 5 mg

Lisinopril 10 mg
Miniaspi 80 mg

27.379

39.155

11.776

22.772

1 192.204,18

192.204

69

7.772,16

29.793

23

17.664,00

23

4.357,12

2025 0000116714171 P SRI WAHYUNI

00766 11/04/2016 Seretide Diskus 250 250 mcg/puff

2026 0000116784268 I TRITARTINAH AZIS

00773 11/04/2016 Thyrozol 10 mg

2027 0000117161572 I HALIMATUS SADIYAH

00778 11/04/2016 Thyrozol 10 mg


Propranolol 10 mg

Harga
Diajukan

1 142.799,58

142.800

23

33.414,40

33.414

46

66.828,80

72.570

69

5.740,80

2028 0000116922587 P NY. SALHAH

00779 11/04/2016 Thyrozol 10 mg

23

33.414,40

33.414

2029 0000116732946 S MOH. MUHRI

00784 11/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

2030 0000116824656 P RADEN HANAFI


HENDRAJANA
2031 0001479470275 P SUMIATI

00802 12/04/2016 Levopar 125 mg komb

69 132.480,00

132.480

00813 12/04/2016 Thyrozol 10 mg

23

33.414,40

33.414

2032 0001128802419 P MOCH.SAHID

00814 12/04/2016 Amlodipine 10 mg

23

9.715,20

21.491

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

2033 0000116971907 P H. MOHAMMAD MANSUR 00822 12/04/2016 Amlodipine 10 mg

23

9.715,20

Miniaspi 80 mg

23

4.357,12

Micardis 80 mg

23 191.360,00

1 142.799,58

2034 0000116952041 P MOHAMAD DRADJID

Halaman :

151

00832 12/04/2016 Seretide Diskus 250 250 mcg/puff

205.432

675.583

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

Spiriva Refill 18 mcg

23 408.252,43

Amlodipine 10 mg

23

Diovan 80 mg

23 114.816,00

2035 0000774781626 P AKHMAD P.TUS

00838 12/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2036 0001860159778 P MUTARIB

00839 12/04/2016 Miniaspi 80 mg

23

4.357,12

55.965

Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Lisinopril 10 mg

23

17.664,00

Foransi 10 10 mg

23

12.335,36

2037 0000116912676 P MOH.ALI NITISASTRO

00840 12/04/2016 Seretide Diskus 250 250 mcg/puff

2038 0000116991753 P MOHAMMAD JUFFRI

00841 12/04/2016 Lisinopril 10 mg

Furosemide 40 mg
00843 12/04/2016 Metformin 500 mg

2039 0000116906376 I SITI FATHAH

2040 0000116782942 P SLAMET SUPRIYADI

2041 0000116835219 P MUNASIK

2042 0000116906859 P H.ACHMAD


MUSJAFFAK,BA

1 142.799,58

142.800

23

17.664,00

20.166

23

2.502,40

69

9.936,00

Glimepiride 4 mg

23

12.659,20

Akarbose 100 mg

46

58.291,20

23 114.816,00

Furosemide 40 mg

23

2.502,40

Allopurinol 100 mg

23

2.531,84

23

11.893,76

Metformin 500 mg

69

9.936,00

Fenofibrate 100 mg

23

31.648,00

00870 12/04/2016 Gemfibrozil 300 mg

23

8.508,16

23

12.659,20

23

8.508,16

Gliclazide 60 mg

23 161.920,00

Lisinopril 10 mg

23

17.664,00

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Gemfibrozil 300 mg

23

8.508,16

00861 12/04/2016 Diovan 80 mg

00866 12/04/2016 Glimepiride 3 mg

Glimepiride 4 mg
2043 0000098237305 I SUKTIYAH ROKAYYAH

2044 0000116818604 P MOH. SALEH HARYADI

Halaman :

152

9.715,20

00871 12/04/2016 Gemfibrozil 300 mg

00872 12/04/2016 Miniaspi 80 mg

80.886

119.850

53.478

21.167

188.092

247.384

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Glimepiride 2 mg

23

Sifrol ER 375 mcg

23 211.968,00

Harga
Diajukan

12.835,84

2045 0001895626462 P SUKARLANA

00874 12/04/2016 Gemfibrozil 300 mg

23

8.508,16

8.508

2046 0000116932882 P DR.H.IMAM


KUSMADI,DSA
2047 0001478151909 P SAFIK

00881 12/04/2016 Berotec MDI 100 mcg/puff

91.854,00

91.854

00892 13/04/2016 Vitamin B6 10 mg

23

3.238,40

14.985

Phenytoin 100 mg

69

11.746,56

2048 0000774077769 P SLAMA

00902 13/04/2016 Stalevo 325 mg komb

46 524.032,00

524.032

2049 0000117004465 P MUHAMAD SYAMSURI

00908 13/04/2016 Gliclazide 60 mg

23 161.920,00

367.352

Amlodipine 10 mg

23

9.715,20

Miniaspi 80 mg

23

4.357,12

Micardis 80 mg

23 191.360,00

00911 13/04/2016 Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Captopril 50 mg

69

12.364,80

2051 0000776138859 P HALIFAH

00912 13/04/2016 Captopril 25 mg

46

4.945,92

4.946

2052 0001410409552 P INDAH LESTARI K

00913 13/04/2016 Vitamin B6 10 mg

23

3.238,40

14.985

Phenytoin 100 mg

69

11.746,56

00915 13/04/2016 Bisoprolol 5 mg

23

18.988,80

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

9.715,20

00928 13/04/2016 Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

00930 13/04/2016 Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

46

6.624,00

00936 13/04/2016 Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Novorapid Flexpen 100 UI/ml

Glimepiride 2 mg

23

12.835,84

69

7.418,88

2050 0000116655388 P BUHARI MUSLIM

2053 0001410240216 P SUPRAPTI

2054 0000159890894 P RUMMINI

2055 0001423361586 P YUK AMALIA

2056 0000166444806 I SUSMAWARI NINGSIH

2057 0000098119484 P SUDARTO

Halaman :

153

00946 13/04/2016 Captopril 25 mg

35.711

220.064

22.595

19.283

147.750

1 107.534,70

7.419

No.

No Ka Peserta

Nama

2058 0000775132558 P MOH.HALIK

No
Rsp

Tgl Pel

Nama Obat

00947 13/04/2016 Glimepiride 4 mg

2060 0000117033221 P ACH. DAILAMI, A.MA

2061 0001094091748 P ABD.KARIM

23

12.659,20

69

9.936,00

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Kalipar 300 mg

23

20.608,00

23

9.715,20

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

Lisinopril 5 mg

23

10.304,00

23 200.192,00

23 209.024,00

23

8.508,16

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

00990 14/04/2016 Amlodipine 10 mg

23

9.715,20

Micardis 80 mg

23 191.360,00

Furosemide 40 mg

46

00954 13/04/2016 Miniaspi 80 mg

00955 13/04/2016 Amlodipine 10 mg

00981 14/04/2016 Harnal Ocas 0,4 mg


Avodart 0,5 mg

2062 0000117081606 I SITI HAMIDAH

2063 0001896947008 P SITI RAMLAH

00985 14/04/2016 Gemfibrozil 300 mg

2064 0000169910662 I ANIFATUR RAHMAH

01007 14/04/2016 Seretide Diskus 250 250 mcg/puff

2065 0001195095767 P INTAN RAHMAWATI

01009 14/04/2016 Alprazolam 0,5 mg

Amitriptyline 25 mg
Haloperidol 0,5 mg

22.595

35.240

31.795

409.216

22.580

206.080

5.004,80
142.800

23

6.300,16

11.334

23

3.297,28

23

1.736,96

01010 14/04/2016 Seretide Diskus 100 100 mcg/puff

2067 0001795026993 P MOHAMMAD HASAN

01011 14/04/2016 Lisinopril 5 mg

2068 0001968746815 P BUNIKRAH

01013 14/04/2016 Miniaspi 80 mg

154

Harga
Diajukan

1 142.799,58

2066 0000166874499 P AHMAD SUHARDI

Halaman :

Harga
Obat

Metformin 500 mg
2059 0000776677522 P M RUJI

Jml
R/N Obt

1 127.049,58

127.050

23

10.304,00

10.304

23

4.357,12

54.228

Bisoprolol 5 mg

23

18.988,80

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Kalipar 300 mg

23

20.608,00

No.

No Ka Peserta

Nama

2069 0001968748536 P HALIMA

2070 0000775014581 P MARROH

2071 0001437498112 P ACHMAD FADALI

2072 0000117024805 P ASNA MANIS TUTIEK

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

01014 14/04/2016 Micardis 80 mg

23 191.360,00

Bisoprolol 5 mg

23

18.988,80

01015 14/04/2016 Miniaspi 80 mg

23

4.357,12

Furosemide 40 mg

12

1.305,60

Concor 2,5 mg

23

21.962,24

23

8.508,16

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Miniaspi 80 mg

23

4.357,12

23

12.659,20

69

9.936,00

01019 14/04/2016 Gemfibrozil 300 mg

01020 14/04/2016 Glimepiride 4 mg


Metformin 500 mg

Harga
Diajukan
210.349

27.625

41.569

22.595

2073 0001302030674 P SUMI TRISNAWATI

01021 14/04/2016 Thyrozol 10 mg

23

33.414,40

33.414

2074 0000116824509 P NURHASAN

01022 14/04/2016 Micardis 80 mg

23 191.360,00

204.196

23

Glimepiride 2 mg

12.835,84

2075 0000775179573 P JULAEHA

01025 14/04/2016 Micardis 80 mg

23 191.360,00

191.360

2076 0000116932871 S TEGUH PRANATA

01027 14/04/2016 Symbicort 80/4.5mcg

1 139.230,00

139.230

2077 0000117047542 S SYAIFUL IRWAN

01044 14/04/2016 Gemfibrozil 300 mg

23

8.508,16

56.952

Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Furosemide 40 mg

23

2.502,40

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

2078 0000117464668 I HJ.KISNANIYAH

01045 14/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

2079 0001544219469 P RIBUT BAIDI

01054 14/04/2016 Depakote ER 250 mg

23

82.225,92

82.226

2080 0000117129486 P MOH SALEH LAHADI

01057 14/04/2016 Miniaspi 80 mg

23

4.357,12

19.489

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

46

6.624,00

23

4.357,12

69

9.936,00

2081 0000210456898 S SYAIFUL UMRON

01059 14/04/2016 Miniaspi 80 mg


Metformin 500 mg

Halaman :

155

26.952

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Glimepiride 4 mg

Jml
R/N Obt
N

23

Harga
Obat

Harga
Diajukan

12.659,20

2082 0001410845848 P HARIS BURHAN

01063 14/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2083 0000116734206 P HASYIRULLAH

01064 14/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2084 0000198713158 I SALIMAH

01065 14/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2085 0000774626253 P MASSORI

01066 14/04/2016 Captopril 12,5 mg

46

3.650,56

4.956

12

1.305,60

23

21.962,24

21.962

2087 0000117042355 P H. KAMARUDIN, S.PD.SD 01080 14/04/2016 Allopurinol 300 mg

23

5.873,28

5.873

2088 0002033907748 P FAHRUR ROSI

23 191.360,00

194.672

23

3.312,00

23

6.947,84

69

9.936,00

23

4.357,12

Isosorbid Dinitrat 5 mg

46

5.181,44

Furosemide 40 mg

23

2.502,40

46

88.320,00

46

6.624,00

23

18.988,80

Glimepiride 2 mg

23

12.835,84

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

Kalipar 300 mg

23

20.608,00

01115 15/04/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

33.414,40

23

1.913,60

Furosemide 40 mg
2086 0000202057446 P M. RAIS YUSUF

01077 14/04/2016 Concor 2,5 mg

01085 14/04/2016 Micardis 80 mg


Metformin 500 mg

2089 0000116779544 P RADEN AYU SRI


KARTININGSIH

01086 14/04/2016 Glicab 80 mg


Metformin 500 mg

2090 0001048326579 P SLAMAN

2091 0001303327844 P MAIMON ABDUL AZIZ

01087 14/04/2016 Miniaspi 80 mg

01088 14/04/2016 Levopar 125 mg komb


Metformin 500 mg

2092 0001048437685 P ACH PURNOMO

2093 0000775067016 P LIPAH

2094 0001048377284 P HAZIZAH

01089 14/04/2016 Bisoprolol 5 mg

01116 15/04/2016 Thyrozol 10 mg


Propranolol 10 mg

16.884

12.041

94.944

62.707

14.985

35.328

2095 0000157258541 P MOEKTIJAH

01119 15/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2096 0000770228695 P MADIN

01120 15/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2097 0001389542163 P ELLY FRIAH NINGSIH

01128 15/04/2016 Propranolol 40 mg

4.793,60

4.794

Halaman :

156

35

No.

No Ka Peserta

Nama

2098 0000116985126 I SUTJI AMINGSIH

2099 0000116916568 P RUSMIYATI

No
Rsp

Tgl Pel

Nama Obat

2101 0000775310365 P LUBABAH

2102 0000774968602 P CICI ROSIDATUL


JANNAH

23

Gliclazide 60 mg

23 161.920,00

Lisinopril 5 mg

23

10.304,00

23

9.715,20

23 114.816,00

23

9.715,20

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

01135 15/04/2016 Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

46

6.624,00

01133 15/04/2016 Amlodipine 10 mg

01134 15/04/2016 Amlodipine 10 mg

01139 15/04/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

2103 0000117122962 P A SUGIANTO

2104 0000116852444 P SAHURI

2105 0000774043244 P MAHMUDI

2106 0001795802398 P FAJARIYAH MULYANI

2107 0001155718539 P ISMAIL

Halaman :

157

Harga
Obat

01129 15/04/2016 Amlodipine 5 mg

Diovan 80 mg
2100 0001388730036 P ABD.HAMID

Jml
R/N Obt

01147 16/04/2016 Akarbose 50 mg

5.505,28

2 215.069,40

1 107.100,00

46

45.926,40

Glicab 80 mg

46

13.895,68

Metformin 500 mg

69

9.936,00

01154 16/04/2016 Novorapid Flexpen 100 UI/ml

3 322.604,10

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Lantus Solostar 100 UI/ml

01156 16/04/2016 Vitamin B6 10 mg

177.729

124.531

32.310

46.662

322.169

69.758

443.776

1 107.100,00

23

3.238,40

Captopril 25 mg

69

7.418,88

Phenytoin 100 mg

69

11.746,56

01159 16/04/2016 Furosemide 40 mg

23

2.502,40

Herbesser CD 100 mg

23 107.956,48

Micardis 80 mg

23 191.360,00

Bisoprolol 5 mg

23

18.988,80

23

3.238,40

01163 16/04/2016 Vitamin B6 10 mg

Harga
Diajukan

22.404

320.808

14.985

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Phenytoin 100 mg

2108 0000117089289 P ACHMAD DJUNAIDI

2110 0000117508195 I SAHAMI

2111 0000774915941 P SUPATMA

2112 0000117029485 I ROFIATUS SYARIFAH

2113 0001426891555 P MUNAJI

2114 0000209712251 P SURATININGSIH

69

11.746,56

23

5.505,28

23

1.648,64

01172 16/04/2016 Amlodipine 5 mg

23

5.505,28

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

23

8.508,16

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

23

4.357,12

Furosemide 40 mg

11

1.196,80

01178 16/04/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

69

7.772,16

Concor 2,5 mg

23

21.962,24

Miniaspi 80 mg

23

4.357,12

01182 16/04/2016 Micardis 40 mg

23 114.816,00

3 400.680,00

01171 16/04/2016 Amlodipine 5 mg

01173 16/04/2016 Gemfibrozil 300 mg

01174 16/04/2016 Miniaspi 80 mg

01180 16/04/2016 Isosorbid Dinitrat 5 mg

Novomix Flexpen 100 UI/ml


2115 0000117112241 S KANIFAN

2116 0000116900245 I SUHENAH

01183 16/04/2016 Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

01185 16/04/2016 Amlodipine 10 mg

23

9.715,20

23

12.835,84

Glimepiride 2 mg
2117 0000772624089 P PUSIHA

01186 16/04/2016 Seretide Diskus 250 250 mcg/puff

2118 0001410380392 P MOH ZAINI

01187 16/04/2016 Furosemide 40 mg

Spironolacton 25 mg
Lisinopril 10 mg

7.154

28.100

31.103

5.554

32.310

34.092

515.496

11.776

22.551

142.800

46

5.004,80

31.942

23

9.273,60

23

17.664,00

01189 16/04/2016 Seretide Diskus 250 250 mcg/puff

2120 0000117454465 P M NASIR

01190 16/04/2016 Bisoprolol 5 mg

158

Harga
Diajukan

1 142.799,58

2119 0000116878162 P SUPRAPTI

Halaman :

Harga
Obat

Glibenklamide 5 mg
2109 0000117508184 P SUHARSO

Jml
R/N Obt

1 142.799,58

142.800

18.988,80

26.761

23

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Isosorbid Dinitrat 5 mg

Jml
R/N Obt
69

7.772,16

23

9.715,20

9.715

1 107.100,00

109.632

01192 16/04/2016 Amlodipine 10 mg

2122 0001874550014 P SULALAH

01194 16/04/2016 Lantus Solostar 100 UI/ml

2123 0000116902923 I MARYAMAH

01197 16/04/2016 Lisinopril 10 mg


Clopidogrel 75 mg

2124 0000162146643 P HARI YANTO, S.H.I

01198 16/04/2016 Akarbose 100 mg

23

2.531,84

23

17.664,00

23 100.096,00

46

58.291,20

Lantus Solostar 100 UI/ml

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

46

13.895,68

69

9.936,00

2125 0000081443474 P MOH. HAIRUDIN SASTRA 01201 16/04/2016 Glicab 80 mg


Metformin 500 mg

Harga
Diajukan

2121 0001048330787 P ABD.AZIS

Allopurinol 100 mg

Harga
Obat

117.760

187.986

1 107.100,00

23.832

2126 0001275799623 P LIYATIN

01202 16/04/2016 Symbicort 160/4.5mcg

1 148.176,00

148.176

2127 0000116926255 I MUSLIMAH

01203 16/04/2016 Gliclazide 60 mg

23 161.920,00

174.358

Furosemide 40 mg

23

2.502,40

Metformin 500 mg

69

9.936,00

23

4.357,12

69

7.772,16

2128 0000116926244 P ABD. SAMAD, A.MA

01204 16/04/2016 Miniaspi 80 mg


Isosorbid Dinitrat 5 mg

12.129

2129 0000117044616 P MOHAMAD RIFAI

01205 16/04/2016 Metformin 500 mg

69

9.936,00

9.936

2130 0000775584922 P HOLILATULHOSNA

01210 16/04/2016 Clorilex 100 100 mg

23 147.200,00

159.123

Trifluoperazin 5 mg

23

11.923,20

46

13.895,68

Metformin 500 mg

69

9.936,00

Akarbose 100 mg

46

58.291,20

2131 0000116930171 I SUDARMI

01211 16/04/2016 Glicab 80 mg

2132 0000775555727 P SAYYIDIN

01222 18/04/2016 Symbicort 160/4.5mcg

2133 0000776857149 P SU'UD

01224 18/04/2016 Miniaspi 80 mg

Amlodipine 10 mg
Levopar 125 mg komb
2134 0000117126369 1 DWI CANDRA BAGUS K.

Halaman :

159

01227 18/04/2016 Clorilex 100 100 mg

82.123

1 148.176,00

148.176

23

4.357,12

102.392

23

9.715,20

46

88.320,00

38.400,00

104.964

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Risperidon 2 mg

46

59.351,04

Carbamazepine 200 mg

23

7.212,80

2135 0000116986509 P SITTI ROKAYYAH NASIR 01230 18/04/2016 Bisoprolol 5 mg

23

18.988,80

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Harga
Diajukan

33.061

2136 0001048422429 P MOHAMMAD RAMLI

01232 18/04/2016 Lisinopril 5 mg

23

10.304,00

10.304

2137 0001971820989 P IMANIYAH

01234 18/04/2016 Thyrozol 10 mg

39

56.659,20

60.486

46

3.827,20

Propranolol 10 mg
2138 0000774381701 P SUNDARI

01238 18/04/2016 Glimepiride 3 mg

23

11.893,76

11.894

2139 0000774902891 P SITI NUR SATRIA

01241 18/04/2016 Thyrozol 10 mg

46

66.828,80

72.570

69

5.740,80

46

66.828,80

46

3.827,20

46

66.828,80

69

5.740,80

23

21.962,24

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

12

1.305,60

46

14.425,60

46

59.351,04

R.01

30

4.224,00

23

17.664,00

23

8.508,16

23

11.893,76

69

9.936,00

Propranolol 10 mg
2140 0000773783019 P KHOTIMATUS

01242 18/04/2016 Thyrozol 10 mg


Propranolol 10 mg

2141 0000774709975 P MAIDAH

01243 18/04/2016 Thyrozol 10 mg


Propranolol 10 mg

2142 0000773505009 P SUPAMI

2143 0000202403452 2 MOH RIFKI NUR WAHID

01244 18/04/2016 Concor 2,5 mg

01251 18/04/2016 Carbamazepine 200 mg


Risperidon 2 mg
Vitamin B6 10 mg

2144 0000116778723 P ZAHID

01256 18/04/2016 Lisinopril 10 mg


Gemfibrozil 300 mg

2145 0000196656726 I SUNIYAH

01266 18/04/2016 Glimepiride 3 mg


Metformin 500 mg

70.656

72.570

32.541

78.001

26.172

21.830

2146 0001048324094 P TURI

01272 18/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

2147 0000102376416 P ADI SUTRISNO

01273 18/04/2016 Miniaspi 80 mg

23

4.357,12

14.072

Amlodipine 10 mg

23

9.715,20

01274 18/04/2016 Amlodipine 10 mg

23

9.715,20

2148 0000776009608 P WASILAH

Halaman :

160

22.374

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Glimepiride 4 mg

2149 0000116932509 P DJUHAIRIJAH

01282 18/04/2016 Gliclazide 60 mg


Fenofibrate 100 mg

Jml
R/N Obt

Harga
Obat

23

23 161.920,00

23

Harga
Diajukan

12.659,20
193.568

31.648,00

2150 0000117062605 P ABDUL QADIR DJAELANI 01284 18/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2151 0000163394548 P NAFSHATUN

23 161.920,00

421.286

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

9.715,20

Akarbose 100 mg

46

58.291,20

01293 18/04/2016 Glimepiride 3 mg

23

11.893,76

69

9.936,00

2152 0000775159198 P AMINA

01288 18/04/2016 Gliclazide 60 mg

Metformin 500 mg

21.830

2153 0001599768628 P PURBOWATI

01299 18/04/2016 Glimepiride 4 mg

23

12.659,20

12.659

2154 0000117161572 I HALIMATUS SADIYAH

01302 18/04/2016 Gliclazide 60 mg

23 161.920,00

161.920

2155 0000147812038 P ABU HASAN, A.PRA.TTD

01305 18/04/2016 Micardis 80 mg

23 191.360,00

201.075

Amlodipine 10 mg

23

9.715,20

01306 18/04/2016 Furosemide 40 mg

12

1.305,60

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

23 191.360,00

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

2158 0000116999245 P BURHAN ALAM SYAH

01311 18/04/2016 Glimepiride 3 mg

23

11.893,76

11.894

2159 0000117079659 P DJIMRON HARDIANTO

01314 18/04/2016 Amlodipine 10 mg

23

9.715,20

38.419

Lisinopril 10 mg

23

17.664,00

Gemfibrozil 300 mg

23

8.508,16

Allopurinol 100 mg

23

2.531,84

2156 0000774511828 P RISKIYAH

2157 0000116978411 P LIMANI

01309 18/04/2016 Micardis 80 mg

18.351

213.955

2160 0000116959522 I RUFIAH

01317 18/04/2016 Gliclazide 60 mg

23 161.920,00

161.920

2161 0002037802634 P ABDULLAH RAHIM

01319 18/04/2016 Micardis 80 mg

23 191.360,00

193.862

23

2.502,40

23

12.835,84

Furosemide 40 mg
2162 0001048339304 P MAS AH

Halaman :

161

01325 18/04/2016 Glimepiride 2 mg

22.772

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Metformin 500 mg

2163 0001095119076 P MOEDENAR

2165 0000775363781 P MOH.HARIRI

69

9.936,00

23

4.357,12

23

9.715,20

23

7.212,80

Phenytoin 100 mg

69

11.746,56

Vitamin B6 10 mg

23

3.238,40

46

33.149,44

23

1.913,60

23

33.414,40

23

1.913,60

23 191.360,00

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

23 191.360,00

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

23

4.357,12

23

17.664,00

01330 19/04/2016 Miniaspi 80 mg

01339 19/04/2016 Carbamazepine 200 mg

01352 19/04/2016 Thyrozol 5 mg


Propranolol 10 mg

2166 0000775898155 P MISPARI

01354 19/04/2016 Thyrozol 10 mg


Propranolol 10 mg

2167 0000774878859 P SANARYAH

2168 0000116981965 I AMANIYAH

2169 0000116668023 P AHMAD KHOIRI

01360 19/04/2016 Micardis 80 mg

01361 19/04/2016 Micardis 80 mg

01370 19/04/2016 Miniaspi 80 mg


Lisinopril 10 mg

2170 000094685084

I SRI SUNINGSIH

Harga
Obat

Amlodipine 10 mg
2164 0000777784127 P SUBAIRI

Jml
R/N Obt

Harga
Diajukan

14.072

22.198

35.063

35.328

203.136

213.955

22.021

01378 19/04/2016 Lantus Solostar 100 UI/ml

1 107.100,00

107.100

2171 0000116984068 I NUR QOMARIL LATIFAH

01386 19/04/2016 Symbicort 160/4.5mcg

1 148.176,00

148.176

2172 0001048397218 P SURAHMI

01388 19/04/2016 Glimepiride 4 mg

23

12.659,20

20.078

69

7.418,88

01389 19/04/2016 Glimepiride 4 mg

23

12.659,20

Akarbose 100 mg

46

58.291,20

Metformin 500 mg

69

9.936,00

01391 19/04/2016 Furosemide 40 mg

12

1.305,60

Captopril 25 mg
2173 0000117011496 P JOKO USMAN

2174 0001301260364 P BUSTAMI

2175 0001282144184 P JUMA'I

Halaman :

162

Novorapid Flexpen 100 UI/ml

2 215.069,40

Lantus Solostar 100 UI/ml

1 107.100,00

01393 19/04/2016 Amlodipine 10 mg

23

9.715,20

80.886

323.475

24.906

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Isosorbid Dinitrat 5 mg

69

7.772,16

Captopril 25 mg

69

7.418,88

Harga
Diajukan

2176 0001266413264 P KOMARIYATUN

01394 19/04/2016 Propranolol 10 mg

46

3.827,20

3.827

2177 0001104491619 P YUDI SANTOSO

01395 19/04/2016 Amlodipine 5 mg

23

5.505,28

49.312

Miniaspi 80 mg

23

4.357,12

Glimepiride 1 mg

23

7.801,60

Fenofibrate 100 mg

23

31.648,00

2178 0000775640698 P MUNIRAH

01406 19/04/2016 Seretide Diskus 100 100 mcg/puff

2179 0000116833915 P MOH. HAKI

01411 19/04/2016 Miniaspi 80 mg

N
N

Captopril 25 mg
2180 0000776033662 P PATINI

01417 19/04/2016 Spiriva Combo 18 mcg

2181 0000775199643 P HOJJEH

01426 19/04/2016 Fenofibrate 100 mg

2183 0001811575416 P M.ATMO

2184 0000117016165 P LILIK SULAIHA

2185 0001372475305 P HARI GUNAWAN

2186 0000775815805 P HAMIMAH

2187 0001435164614 P ABD.WAHID SALIM

Halaman :

163

127.050

23

4.357,12

9.303

46

4.945,92

1 192.204,18

192.204

23

31.648,00

44.307

23

12.659,20

01428 19/04/2016 Furosemide 40 mg

23

2.502,40

Amlodipine 10 mg

23

9.715,20

23

17.075,20

Spironolacton 25 mg

23

9.273,60

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

23

33.414,40

Propranolol 10 mg

46

3.827,20

01444 20/04/2016 Furosemide 40 mg

23

2.502,40

Allopurinol 300 mg

23

5.873,28

Micardis 80 mg

23 191.360,00

Glikuidon 30 mg

23

27.968,00

23

4.357,12

Amlodipine 5 mg

23

5.505,28

Gemfibrozil 300 mg

23

8.508,16

23

9.715,20

Glimepiride 4 mg
2182 0001080391893 P MOHAMMD WARI

1 127.049,58

01434 19/04/2016 Ramipril 5 mg

01442 20/04/2016 Thyrozol 10 mg

01450 20/04/2016 Miniaspi 80 mg

01460 20/04/2016 Amlodipine 10 mg

12.218

36.623

37.242

227.704

18.371

9.715

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

2188 0000098228834 P ABD. KAMAR

01461 20/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

2189 0000777308499 P ABD SAKUR

01463 20/04/2016 Carbamazepine 200 mg

23

7.212,80

22.198

Phenytoin 100 mg

69

11.746,56

Vitamin B6 10 mg

23

3.238,40

2190 0000117014984 I SITI RAHMAH

01464 20/04/2016 Concor 2,5 mg

23

21.962,24

21.962

2191 0000173770918 2 ANISATUL KAMILAH

01466 20/04/2016 Propranolol 40 mg

23

3.150,08

3.150

2192 0000116847832 P MOHAMMAD BADRUL

01469 20/04/2016 Miniaspi 80 mg

23

4.357,12

36.207

Glimepiride 2 mg

23

12.835,84

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

Metformin 500 mg

69

9.936,00

46

66.828,80

12

1.305,60

69 132.480,00

132.480

2195 0000116809828 P FENDYK TRIWICAKSONO 01475 20/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2196 0000773943884 P ROHMAN SODIK

01481 20/04/2016 Vitamin B6 10 mg

23

3.238,40

14.985

Phenytoin 100 mg

69

11.746,56

2193 0000776904535 P RUSTIANI

01470 20/04/2016 Thyrozol 10 mg


Furosemide 40 mg

2194 0001410230518 P MUSLIMAH

01474 20/04/2016 Levopar 125 mg komb

2197 0000117369617 P ACHMAD AS'AD

01487 20/04/2016 Seretide Diskus 250 250 mcg/puff

2198 0000116950241 P MOH.DAHURI

01488 20/04/2016 Furosemide 40 mg

Ramipril 5 mg

68.134

1 142.799,58

142.800

23

2.502,40

31.707

23

17.075,20

Spironolacton 25 mg

23

9.273,60

Digoksin 0,25 mg

23

2.855,68

2199 0000778391829 P MISYANI

01489 20/04/2016 Thyrozol 10 mg

23

33.414,40

33.414

2200 0000775145169 P TUMA

01498 20/04/2016 Captopril 25 mg

69

7.418,88

7.419

2201 0000775301602 P MAHRUMAH

01499 20/04/2016 Thyrozol 10 mg

23

33.414,40

33.414

2202 0001297182249 P HANIYAH

01500 20/04/2016 Furosemide 40 mg

12

1.305,60

11.213

Bisoprolol 5 mg

12

9.907,20

2203 0001451338929 P HATIB

01503 20/04/2016 Micardis 80 mg

23 191.360,00

191.360

2204 0000772911753 P SUKRI

01505 20/04/2016 Miniaspi 80 mg

23

4.357,12

33.620

Halaman :

164

No.

No Ka Peserta

Nama

2205 0000116982573 P FATIMAH FANKIYAH

No
Rsp

Tgl Pel

Nama Obat

2207 0001080029665 I DJUMAIJAH

2208 0001095194215 P SUMIK

2209 0001293930088 P PRIHATINAH

Harga
Obat

Bisoprolol 5 mg

23

18.988,80

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

01509 20/04/2016 Olandoz 10 10 mg

23 329.728,00

23

23 329.728,00

Amlodipine 5 mg

23

5.505,28

Nopres 20 mg

23

12.718,08

Candesartan Cilexetil 8 mg

23

91.264,00

23

8.508,16

Captopril 25 mg

69

7.418,88

Metformin 500 mg

69

9.936,00

23

4.357,12

Gemfibrozil 300 mg

23

8.508,16

Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Allopurinol 300 mg

23

5.873,28

Metformin 500 mg

69

9.936,00

01519 20/04/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

Nopres 20 mg
2206 0000116932904 P DR.HANDOJO,MPH

Jml
R/N Obt

01510 20/04/2016 Olandoz 10 10 mg

01511 20/04/2016 Gemfibrozil 300 mg

01515 20/04/2016 Miniaspi 80 mg

Glimepiride 4 mg

Harga
Diajukan

342.446

12.718,08
439.215

25.863

56.054

22.595

2210 0000774115964 P SUDI

01523 20/04/2016 Thyrozol 10 mg

46

66.828,80

66.829

2211 0001313587462 P TOYANI

01525 20/04/2016 Miniaspi 80 mg

23

4.357,12

4.357

2212 0000117516161 P SUSI AGUSTIN, AMA.PD

01526 20/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2213 0001048724583 P BUTIYAH

01528 20/04/2016 Amlodipine 10 mg

23

9.715,20

14.072

23

4.357,12

23

16.574,72

23

3.150,08

46

66.828,80

35

4.793,60

Miniaspi 80 mg
2214 0001894864252 P MUAYYAH

01538 20/04/2016 Thyrozol 5 mg


Propranolol 40 mg

2215 0000774820236 P SITTI FATMA

01540 20/04/2016 Thyrozol 10 mg


Propranolol 40 mg

Halaman :

165

19.725

71.622

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

2216 0000163914131 P SUNARDI

01542 20/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2217 0001304457513 P JUMANI

01544 20/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

271.158

2218 0000199657225 I UMI SULCHAH

Bisoprolol 5 mg

23

18.988,80

Spironolacton 25 mg

23

9.273,60

Clopidogrel 75 mg

23 100.096,00

23

12.835,84

69

9.936,00

23

8.508,16

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

01565 21/04/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

01549 21/04/2016 Glimepiride 2 mg


Metformin 500 mg

2219 0000775644276 P MISKIYAH

2220 0001048512159 P ABD.GAFUR

01550 21/04/2016 Gemfibrozil 300 mg

2221 0000116950871 P MOH. MAHAT

01580 21/04/2016 Spiriva Combo 18 mcg

2222 0000116559944 P MUHAMAD TRISWARNO

01581 21/04/2016 Alprazolam 0,5 mg

Amitriptyline 25 mg

22.772

37.212

14.985

1 192.204,18

192.204

23

6.300,16

8.020

12

1.720,32

2223 0000116992427 P MAS`AT

01582 21/04/2016 Glimepiride 4 mg

23

12.659,20

12.659

2224 0000117017785 P ABD RAHMAN

01586 21/04/2016 Glimepiride 2 mg

23

12.835,84

12.836

2225 0001477910441 P MOH.SHUBAIH AFANDI

01589 21/04/2016 Glimepiride 3 mg

23

11.893,76

13.199

12

1.305,60

23

11.893,76

46

6.624,00

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

01600 21/04/2016 Klobazam 10 mg

46

52.992,00

Risperidon 2 mg

46

59.351,04

23

8.508,16

69

12.364,80

23

7.212,80

Furosemide 40 mg
2226 0000116935661 P H. ABDUL MUGID

01592 21/04/2016 Glimepiride 3 mg


Metformin 500 mg

2227 0000777477082 P SURYADI

2228 0000776796941 P DEDI

2229 0000116823262 P SUTARSIH

01593 21/04/2016 Miniaspi 80 mg

01601 21/04/2016 Gemfibrozil 300 mg


Captopril 50 mg

2230 0000775174612 P ABD RAHMAN

Halaman :

166

01602 21/04/2016 Carbamazepine 200 mg

18.518

13.435

112.343

20.873

22.198

No.

No Ka Peserta

Nama

2231 0000774393614 P GUNAWAN AGUS


SUSANTO

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

46

59.351,04

Clorilex 100 100 mg

38.400,00

Alprazolam 0,5 mg

23

6.300,16

01603 21/04/2016 Risperidon 2 mg

Harga
Diajukan

104.051

2232 0000116984193 P MAZHAR

01604 21/04/2016 Diovan 80 mg

23 114.816,00

114.816

2233 0000117015974 I NADIYATUN

01605 21/04/2016 Amitriptyline 25 mg

35

5.017,60

11.318

23

6.300,16

01610 21/04/2016 Trifluoperazin 5 mg

23

11.923,20

Clorilex 100 100 mg

38.400,00

Klorpromazin 100 mg

12

2.211,84

23

11.893,76

69

7.418,88

23

11.923,20

23

29.675,52

23

33.414,40

Propranolol 10 mg

23

1.913,60

2238 0002035567901 P RAMLAH

01615 21/04/2016 Metformin 500 mg

69

9.936,00

9.936

2239 0000049204271 P HATIMAH

01617 21/04/2016 Bisoprolol 5 mg

23

18.988,80

31.118

Miniaspi 80 mg

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

23

11.893,76

Metformin 500 mg

69

9.936,00

01627 21/04/2016 Metformin 500 mg

69

9.936,00

23

12.659,20

23

33.414,40

23

1.913,60

46

66.828,80

35

4.793,60

Alprazolam 0,5 mg
2234 0001482889037 P SUGIYONO

2235 0000204334334 P EMAD

01611 21/04/2016 Glimepiride 3 mg


Captopril 25 mg

2236 0000202742728 1 ALIFAH RIZKA PUTRI

01612 21/04/2016 Trifluoperazin 5 mg


Risperidon 2 mg

2237 0001896921167 P ZUBAIDAH

2240 0001429643103 P SUNA

2241 0000117003791 P ZAIMAH

01613 21/04/2016 Thyrozol 10 mg

01624 21/04/2016 Glimepiride 3 mg

Glimepiride 4 mg
2242 0000775479273 P HOTIMAH

01628 21/04/2016 Thyrozol 10 mg


Propranolol 10 mg

2243 0000775526951 P NATIFAH

01629 21/04/2016 Thyrozol 10 mg


Propranolol 40 mg

Halaman :

167

52.535

19.313

41.599

35.328

21.830

22.595

35.328

71.622

No.

No Ka Peserta

Nama

2244 0000117082326 P SUMARWAN

2245 0000092887661 P ROEKMINI


ASMARAWITJITRA

2246 0000117087456 P SULAIMAN

2247 0000775889414 P DUHAN

2248 0001138576882 P MISKIATUN HASANAH

No
Rsp

Tgl Pel

Nama Obat

01631 21/04/2016 Isosorbid Dinitrat 5 mg

Jml
R/N Obt

Harga
Obat

69

7.772,16

Allopurinol 300 mg

23

5.873,28

Miniaspi 80 mg

23

4.357,12

Metformin 500 mg

23

3.312,00

01633 21/04/2016 Miniaspi 80 mg

23

4.357,12

Micardis 80 mg

23 191.360,00

Allopurinol 300 mg

23

5.873,28

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

23

2.502,40

23

8.508,16

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Bisoprolol 5 mg

23

18.988,80

Micardis 40 mg

23 114.816,00

23

Micardis 40 mg

23 114.816,00

01644 21/04/2016 Nifedipin 10 mg

69

9.715,20

Captopril 50 mg

69

12.364,80

01636 21/04/2016 Gemfibrozil 300 mg

01639 21/04/2016 Allopurinol 300 mg

5.873,28

Harga
Diajukan
21.315

211.865

168.279

120.689

22.080

2249 0000081456838 P SOEHARTI

01648 21/04/2016 Diovan 80 mg

23 114.816,00

114.816

2250 0000117130533 P BAHRI

01649 21/04/2016 Gemfibrozil 300 mg

23

8.508,16

18.812

23

10.304,00

23

6.300,16

46 379.776,00

01653 22/04/2016 Miniaspi 80 mg

23

4.357,12

Bisoprolol 5 mg

23

18.988,80

Lisinopril 5 mg
2251 0001048494688 P ERFAN ARIFANDI

01652 22/04/2016 Alprazolam 0,5 mg


Olandoz 5 5 mg

2252 0000774575954 P SRI ROFIATUN

2253 0000116932116 P DJAMALIYAH

Halaman :

168

01656 22/04/2016 Novorapid Flexpen 100 UI/ml

3 322.604,10

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

9.715,20

386.076

23.346

630.779

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Lantus Solostar 100 UI/ml

2254 0000977368588 S ABRAHAM AJIE

01660 22/04/2016 Clorilex 100 100 mg


Depakote 250 mg

2255 0001431541719 P HOSNIYAH

01664 22/04/2016 Alprazolam 0,5 mg


Clorilex 100 100 mg

Jml
R/N Obt
N

Harga
Obat

Harga
Diajukan

1 107.100,00

12

76.800,00

46

98.918,40

23

6.300,16

38.400,00

175.718

44.700

2256 0001896416098 P MOH.TAHIR

01669 22/04/2016 Harnal D 0,2 mg

23 170.752,00

170.752

2257 0000116984057 P MARTINUS EKO


CHRISTANTO
2258 0001896757402 P MARYAMAH

01676 22/04/2016 Symbicort 160/4.5mcg

1 148.176,00

148.176

01682 22/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2259 0000775696364 P HASANAH

01687 22/04/2016 Glimepiride 2 mg

23

12.835,84

22.772

Metformin 500 mg

69

9.936,00

01696 22/04/2016 Furosemide 40 mg

23

2.502,40

23

17.664,00

2260 0001471488311 P BUREYEM

Lisinopril 10 mg

20.166

2261 0001810566764 P SAKINAH

01700 22/04/2016 Symbicort 80/4.5mcg

1 139.230,00

139.230

2262 0001827143379 P SUHAIRIYAH

01701 22/04/2016 Novorapid Flexpen 100 UI/ml

1 107.534,70

214.635

1 107.100,00

Lantus Solostar 100 UI/ml


2263 0000774324404 P HASUNAH

01702 22/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

2264 0000116556761 I RUSMAH

01704 22/04/2016 Bisoprolol 5 mg

23

18.988,80

143.520

Amlodipine 10 mg

23

9.715,20

Diovan 80 mg

23 114.816,00

23

9.273,60

46

5.004,80

23

26.496,00

35

4.793,60

01707 22/04/2016 Trifluoperazin 5 mg

23

11.923,20

Clorilex 100 100 mg

12

76.800,00

Klorpromazin 100 mg

46

8.478,72

23

12.659,20

2265 0000776463107 P BAISUNI

01705 22/04/2016 Spironolacton 25 mg


Furosemide 40 mg

2266 0000776097775 P MURSID K.

01706 22/04/2016 Spironolacton 100 mg


Propranolol 40 mg

2267 0000775334878 P SUBAIDI

2268 0000205542325 S ARIF RAHMAN HAKIM

Halaman :

169

01710 22/04/2016 Glimepiride 4 mg


Lantus Solostar 100 UI/ml

Metformin 500 mg

1 107.100,00
69

9.936,00

14.278

31.290

97.202

129.695

No.

No Ka Peserta

Nama

2269 0000116940396 P JAJUK KUSTIRAHAYU

2270 0000206001606 P MOH. SURI

No
Rsp

Tgl Pel

Nama Obat

01714 23/04/2016 Miniaspi 80 mg

Harga
Obat

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Lansoprazole 30 mg

23

13.925,12

23 191.360,00

69

9.936,00

23

18.988,80

Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Metformin 500 mg

69

9.936,00

Lantus Solostar 100 UI/ml

2 214.200,00

01715 23/04/2016 Micardis 80 mg


Metformin 500 mg

2271 0000116963717 P SAUDI IDRIS

Jml
R/N Obt

01722 23/04/2016 Bisoprolol 5 mg

Harga
Diajukan
27.997

201.296

270.504

2272 0000116909998 P MAMNU'AH, A.MA

01728 23/04/2016 Diovan 80 mg

23 114.816,00

114.816

2273 0000116970647 P UDDIN

01741 23/04/2016 Levopar 125 mg komb

69 132.480,00

275.280

Seretide Diskus 250 250 mcg/puff

1 142.799,58

2274 0000116986509 P SITTI ROKAYYAH NASIR 01742 23/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2275 0000774148397 P BUSIYAH

23

12.659,20

22.595

69

9.936,00

01751 23/04/2016 Glimepiride 4 mg


Metformin 500 mg

2276 0001961579406 P MUSARAH

01753 23/04/2016 Seretide Diskus 250 250 mcg/puff

2277 0000777983501 P FAISAL

01754 23/04/2016 Amlodipine 10 mg

1 142.799,58

142.800

23

9.715,20

28.704

23

18.988,80

23

12.835,84

69

9.936,00

23

5.505,28

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

Bisoprolol 5 mg
2278 0000117370091 P H.MASJHURI

01755 23/04/2016 Glimepiride 2 mg


Metformin 500 mg

2279 0000117021227 P MOHAMAD HARIYADI D

01756 23/04/2016 Amlodipine 5 mg

22.772

20.490

2280 0000117048767 P MARSUKI

01765 23/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

2281 0001410231082 P MASKUR

01766 23/04/2016 Miniaspi 80 mg

23

4.357,12

13.435

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

12

1.305,60

01767 23/04/2016 Amlodipine 10 mg

23

9.715,20

2282 0001328188138 P MOCH.RIDA'I

Halaman :

170

90.602

No.

No Ka Peserta

Nama

2283 0001328189646 P SUNAR HAYATI

No
Rsp

Tgl Pel

Nama Obat

Harga
Obat

69

9.936,00

Glimepiride 4 mg

23

12.659,20

Akarbose 100 mg

46

58.291,20

23 191.360,00

23

9.715,20

46

33.149,44

69

5.740,80
7.914.200

97.751

01768 23/04/2016 Micardis 80 mg

01769 23/04/2016 Thyrozol 5 mg


Propranolol 10 mg

2285 0000780402251 P AGUS

01770 23/04/2016 Top Up Hemofilia RS B Reg I NULL

2286 0000774128632 P KIYEH

01772 23/04/2016 Thyrozol 10 mg

1 7.914.200,0
0
33.414,40
23

2287 0001900303334 P ALI HARTONO

01773 23/04/2016 Risperidon 2 mg

46

59.351,04

38.400,00

23

12.659,20

69

9.936,00

Clorilex 100 100 mg


2288 0000116828717 I HATIYAH

Harga
Diajukan

Metformin 500 mg

Amlodipine 10 mg
2284 0000775228105 P FADILAH

Jml
R/N Obt

01775 23/04/2016 Glimepiride 4 mg


Metformin 500 mg

201.075

38.890

33.414

22.595

2289 0000117097457 P MAS`UDI

01776 23/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2290 0001104077812 P AGUS SANTOSO

01777 23/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2291 0001279734884 P EKO MARDIONO

01780 23/04/2016 Lisinopril 10 mg

23

17.664,00

172.593

Miniaspi 80 mg

23

4.357,12

Seretide Diskus 250 250 mcg/puff

Isosorbid Dinitrat 5 mg

69

7.772,16

23

2.502,40

2.502

1 142.799,58

142.800

1 142.799,58

2292 0000774278335 P MATSIRAT

01781 23/04/2016 Furosemide 40 mg

2293 0001080071234 I NASIYAH

01783 23/04/2016 Seretide Diskus 250 250 mcg/puff

2294 0001410301225 P SARI

01786 23/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

2295 000774177153

01787 23/04/2016 Lisinopril 10 mg

23

17.664,00

20.166

Furosemide 40 mg

23

2.502,40

01788 23/04/2016 Amlodipine 10 mg

23

9.715,20

23

17.664,00

23

16.574,72

Propranolol 10 mg

69

5.740,80

01797 23/04/2016 Olandoz 10 10 mg

46 659.456,00

P HATIB

2296 0000773881031 P SABIDIN

Lisinopril 10 mg
2297 0000775920802 P ROMLAH

2298 0000773886341 P NABILAH MAULANA


ARIFIN

Halaman :

171

01789 23/04/2016 Thyrozol 5 mg

27.379

22.316

662.753

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Amitriptyline 25 mg

Jml
R/N Obt

Harga
Obat

23

3.297,28

Harga
Diajukan

2299 0001895639973 P SUBAGIO

01807 25/04/2016 Miniaspi 80 mg

23

4.357,12

4.357

2300 0001895626462 P SUKARLANA

01809 25/04/2016 Nopres 20 mg

23

12.718,08

117.348

Merlopam 2 mg

23

39.479,04

Ramipril 10 mg

23

29.822,72

Risperidon 1 mg

23

35.328,00

23

18.988,80

23

9.715,20

01815 25/04/2016 Bisoprolol 5 mg

23

18.988,80

Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

23

4.357,12

Lisinopril 10 mg

23

17.664,00

Isosorbid Dinitrat 5 mg

69

7.772,16

Allopurinol 300 mg

23

5.873,28

Metformin 500 mg

69

9.936,00

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Isosorbid Dinitrat 5 mg

69

7.772,16

Allopurinol 300 mg

23

5.873,28

46

66.828,80

69

5.740,80

23

8.508,16

Miniaspi 80 mg

23

4.357,12

Lisinopril 10 mg

23

17.664,00

01827 25/04/2016 Bisoprolol 5 mg

23

18.988,80

Miniaspi 80 mg

23

4.357,12

Symbicort 160/4.5mcg

2301 0000773891076 P ARIYAH

01810 25/04/2016 Bisoprolol 5 mg


Amlodipine 10 mg

2302 0000117079086 P MOH. SAYUDI

2303 0000117130037 P HERI WIDIASTUTI

2304 0000116931789 P DARSONO

2305 0001599774322 P SITI JUMNA

01820 25/04/2016 Miniaspi 80 mg

01821 25/04/2016 Miniaspi 80 mg

01822 25/04/2016 Thyrozol 10 mg


Propranolol 10 mg

2306 0000116999245 P BURHAN ALAM SYAH

2307 0000117124547 P RUKIYATUN


KUSDWITANTY

2308 0000116909076 I S U R A T M I

Halaman :

172

01824 25/04/2016 Gemfibrozil 300 mg

01828 25/04/2016 Glimepiride 3 mg

28.704

33.061

45.603

27.718

72.570

30.529

171.522

1 148.176,00
23

11.893,76

23.714

No.

No Ka Peserta

Nama

2309 0001410235659 P SYAIFUL ZAIN

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Gemfibrozil 300 mg

23

8.508,16

Metformin 500 mg

23

3.312,00

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Ramipril 5 mg

23

17.075,20

01829 25/04/2016 Miniaspi 80 mg

Harga
Diajukan

29.204

2310 0001048324094 P TURI

01830 25/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

2311 0000776116258 P SUTIYEH

01832 25/04/2016 Miniaspi 80 mg

23

4.357,12

15.967

Furosemide 40 mg

12

1.305,60

Lisinopril 5 mg

23

10.304,00

69

7.772,16

Miniaspi 80 mg

23

4.357,12

Amlodipine 5 mg

23

5.505,28

01842 25/04/2016 Amlodipine 5 mg

23

5.505,28

Miniaspi 80 mg

23

4.357,12

Concor 2,5 mg

23

21.962,24

Candesartan Cilexetil 8 mg

23

91.264,00

2312 0001048545955 P LENI IRAWATI

2313 0000116798905 P HENDRO SANTOSO

01841 25/04/2016 Isosorbid Dinitrat 5 mg

17.635

123.089

2314 0000776141583 P ROHMATUSSOLIHAH

01846 25/04/2016 Risperidon 1 mg

46

70.656,00

70.656

2315 0000098244257 I HASIJAH

01851 25/04/2016 Glimepiride 3 mg

23

11.893,76

11.894

23 329.728,00

353.574

46

23 191.360,00

23

2316 0001891796499 P MOHAMMAD MUTAMMAM 01857 25/04/2016 Olandoz 10 10 mg


Trifluoperazin 5 mg
2317 0000116985519 P R. SANIJAH

01858 25/04/2016 Micardis 80 mg


Amlodipine 10 mg

2318 0000773892494 P KAMARIATUL JANNAH

01859 25/04/2016 Seretide Diskus 250 250 mcg/puff

2319 0000776569184 P HOTIJA

01860 25/04/2016 Captopril 12,5 mg

Metformin 500 mg
Glimepiride 4 mg
2320 0000776168515 P MOH.HEKAM

Halaman :

173

23.846,40
201.075

9.715,20

1 142.799,58

142.800

69

5.475,84

28.071

69

9.936,00

23

12.659,20

23

7.212,80

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

46

7.831,04

01868 25/04/2016 Carbamazepine 200 mg

18.282

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

2321 0000775630787 P MUSLIHAH

01869 25/04/2016 Glimepiride 4 mg

23

12.659,20

12.659

2322 0000116917176 I MAISINTI

01870 25/04/2016 Captopril 12,5 mg

69

5.475,84

28.071

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

01881 25/04/2016 Amlodipine 5 mg

23

5.505,28

5.505

23

18.988,80

212.851

23 191.360,00

Furosemide 40 mg

23

2.502,40

01892 25/04/2016 Amlodipine 10 mg

23

9.715,20

2323 0001048689843 P MURAKED

2324 0000116812721 P DRS. ACHMAD SUBAKKI, 01883 25/04/2016 Bisoprolol 5 mg


M.PD
Micardis 80 mg

2325 0000117070615 P MAIHASANAH

Apidra Solostar 100 UI/ml

Lisinopril 10 mg

2326 0000116811123 P NURJA HAIRILLAH

01899 25/04/2016 Seretide Diskus 250 250 mcg/puff

2327 0000776892532 P MISRIYAH

01900 25/04/2016 Thyrozol 10 mg

N
N

Propranolol 10 mg

226.875

2 199.495,80
23

17.664,00

1 142.799,58

142.800

23

33.414,40

35.328

23

1.913,60

2328 0000977975201 P NUR HIDAYAT

01902 25/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2329 0000116980828 P ADY CAHYANING

01903 25/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2330 0000116886137 I SITI AISJAH

01904 25/04/2016 Glimepiride 3 mg

23

11.893,76

58.983

Amlodipine 5 mg

23

5.505,28

Metformin 500 mg

69

9.936,00

Fenofibrate 100 mg

23

31.648,00

2331 0000116886126 P MOCH. IKSAN

01905 25/04/2016 Amlodipine 5 mg

23

5.505,28

5.505

2332 0000117070503 P HARIS

01906 25/04/2016 Gemfibrozil 600 mg

23

19.989,76

42.585

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

23

5.505,28

Metformin 500 mg

69

9.936,00

Akarbose 100 mg

46

58.291,20

23 161.920,00

23

2333 0000776314855 P HELMIYAH SUNAMI

2334 0000116816016 P SUPARMAN

01917 25/04/2016 Amlodipine 5 mg

01918 25/04/2016 Gliclazide 60 mg


Glimepiride 3 mg

Halaman :

174

11.893,76

73.732

176.346

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Allopurinol 100 mg

2335 0000116987782 P UMI FATIROH

01922 25/04/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

2336 0000775292117 P BUSINI

01924 25/04/2016 Thyrozol 10 mg

Jml
R/N Obt
N

23

Harga
Obat

Harga
Diajukan

2.531,84

4 430.138,80

2 214.200,00

644.339

23

33.414,40

23

1.913,60

23 200.192,00

Avodart 0,5 mg

23 209.024,00

01943 26/04/2016 Miniaspi 80 mg

23

4.357,12

Amlodipine 10 mg

23

9.715,20

Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

01948 26/04/2016 Amlodipine 10 mg

23

9.715,20

Ramipril 5 mg

23

17.075,20

Allopurinol 100 mg

23

2.531,84

Glimepiride 4 mg

23

12.659,20

2340 0000169748289 S ARIF SYABAN


01949 26/04/2016 Gemfibrozil 300 mg
HIDAYATULLAH
2341 0001280212547 P MOHAMMAD ZAIFULLAH 01950 26/04/2016 Levopar 125 mg komb
ZIN
Amlodipine 10 mg

23

8.508,16

8.508

46

88.320,00

98.035

23

9.715,20

2342 0000116940699 I SUJANI

23

8.508,16

Micardis 80 mg

23 191.360,00

Glimepiride 3 mg

23

11.893,76

23

33.414,40

69

5.740,80

23

17.664,00

Propranolol 10 mg
2337 0001676182847 P SHALEH

2338 0000116828032 P SLAMET AGUSTIAWAN

2339 0000116963684 P SATUAH JD SURI

2343 0000775485966 P ARTINI

01935 26/04/2016 Harnal Ocas 0,4 mg

01956 26/04/2016 Gemfibrozil 300 mg

01958 26/04/2016 Thyrozol 10 mg


Propranolol 10 mg

2344 0001317289937 P HAIRIYAH

01959 26/04/2016 Lisinopril 10 mg


Novorapid Flexpen 100 UI/ml

4 430.138,80

Lantus Solostar 100 UI/ml

1 107.100,00

35.328

409.216

29.057

41.981

211.762

39.155

554.903

2345 0001311944365 P ATIYEH

01965 26/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

2346 0000197467569 1 NURCHOLIS SETIAWAN


ALI

01970 26/04/2016 Carbamazepine 200 mg

46

14.425,60

25.053

46

3.473,92

Haloperidol 0,5 mg

Halaman :

175

No.

No Ka Peserta

Nama

2347 0001200312955 P RYAN YULITA

2348 0002034135101 P MOH. ASMONI

No
Rsp

Jml
R/N Obt

Harga
Obat

Vitamin B6 10 mg

R.01

23

3.238,40

Phenytoin 100 mg

R.01

23

3.915,52

23

33.414,40

Propranolol 10 mg

23

1.913,60

01981 26/04/2016 Amlodipine 10 mg

23

9.715,20

23

12.659,20

Tgl Pel

Nama Obat

01979 26/04/2016 Thyrozol 10 mg

Glimepiride 4 mg
2349 0000776203514 P MOH.SAHA

2350 0000774156453 P MUHIR

01994 26/04/2016 Novorapid Flexpen 100 UI/ml

Harga
Diajukan

35.328

22.374

2 215.069,40

Micardis 80 mg

23 191.360,00

Amlodipine 10 mg

23

9.715,20

Furosemide 40 mg

23

2.502,40

02001 26/04/2016 Propranolol 10 mg

46

3.827,20

46

33.149,44

23

2.502,40

2.502

Thyrozol 5 mg

418.647

36.977

2351 0000117130421 P SUPARMAN

02002 26/04/2016 Furosemide 40 mg

2352 0000116985047 I SUNARTI

02004 26/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2353 0000116828943 P ABDULLAH, S.AG

02009 26/04/2016 Micardis 80 mg

23 191.360,00

544.294

Bisoprolol 5 mg

23

Novorapid Flexpen 100 UI/ml

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

Lantus Solostar 100 UI/ml

2354 0000775427951 P ROFIK

02010 26/04/2016 Amlodipine 10 mg

1 107.100,00
23

9.715,20

Lisinopril 10 mg

23

17.664,00

Fenofibrate 100 mg

23

31.648,00

02012 26/04/2016 Top Up Hemofilia RS B Reg I NULL

2356 0000780402251 P AGUS

02028 26/04/2016 Top Up Hemofilia RS B Reg I NULL

2357 0001328705921 P SUMROTI

02037 26/04/2016 Berotec MDI 100 mcg/puff

2358 0000172249514 3 INDAH RETNO K. B. U.


2359 0000116983528 P JUHAIRIYAH

59.027

7.914.200

1 7.914.200,0
0
1 7.914.200,0
0
1 91.854,00

02038 26/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

02050 27/04/2016 Miniaspi 80 mg

23

4.357,12

19.931

69

7.772,16

Isosorbid Dinitrat 5 mg

176

2 215.069,40

2355 0000780212463 P ACH.SAUKI

Halaman :

18.988,80

7.914.200
91.854

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat
Glimepiride 1 mg

2360 0000775628436 P MUSARROFAH

2361 0001541078673 P SARTO

Jml
R/N Obt

Harga
Obat

23

7.801,60

46

66.828,80

Propranolol 10 mg

46

3.827,20

02062 27/04/2016 Furosemide 40 mg

23

2.502,40

23

21.962,24

02054 27/04/2016 Thyrozol 10 mg

Concor 2,5 mg

Harga
Diajukan

70.656

24.465

2362 0000116997671 P R HERRY TRIATMOKO

02069 27/04/2016 Trifluoperazin 5 mg

46

23.846,40

23.846

2363 0000117027584 P ABD HALIK

02081 27/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

2364 0000776536907 P HOLILAH

02083 27/04/2016 Miniaspi 80 mg

23

4.357,12

12.129

69

7.772,16

Isosorbid Dinitrat 5 mg
2365 0001410125837 P HAWATI

02092 27/04/2016 Symbicort 80/4.5mcg

1 139.230,00

139.230

2366 0000775698221 P SUMIH

02093 27/04/2016 Symbicort 80/4.5mcg

1 139.230,00

139.230

2367 0001410060846 P SRI TARI PUSPA SAFA

02118 27/04/2016 Vitamin B6 10 mg

23

3.238,40

14.985

Phenytoin 100 mg

69

11.746,56

2368 0000775327386 P MUSLIMAH

02119 27/04/2016 Bisoprolol 5 mg

23

18.988,80

18.989

2369 0000167005449 1 ARIEF SALDI


WARDIANNUR

02121 27/04/2016 Vitamin B6 10 mg

23

3.238,40

14.985

Phenytoin 100 mg

69

11.746,56

2370 0000776556483 P MUDIAH

02124 27/04/2016 Furosemide 40 mg

23

2.502,40

2.502

2371 0002033010538 P SAHAREM

02128 27/04/2016 Symbicort 160/4.5mcg

1 148.176,00

148.176

2372 0000116932893 I MERRY KONSTANTIN

02131 27/04/2016 Lisinopril 10 mg

23

17.664,00

27.600

Metformin 500 mg

69

9.936,00

02132 27/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

02133 27/04/2016 Bisoprolol 5 mg

23

18.988,80

41.761

Glimepiride 2 mg

23

12.835,84

Metformin 500 mg

69

9.936,00

2373 0000116932882 P DR.H.IMAM


KUSMADI,DSA
2374 0000774638943 P ROHEMAH

2375 0001898788768 P ZAKIYAH

02136 27/04/2016 Captopril 50 mg

69

12.364,80

12.365

2376 0000198517342 I IZZATI

02137 27/04/2016 Glimepiride 3 mg

23

11.893,76

170.006

Metformin 500 mg

69

9.936,00

Symbicort 160/4.5mcg

1 148.176,00

23 191.360,00

2377 0000117565828 P LAILA SUSANTI, S.PD

Halaman :

177

02140 27/04/2016 Micardis 80 mg

210.349

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan

Bisoprolol 5 mg

23

18.988,80

2378 0000778243601 P SURING

02144 27/04/2016 Captopril 25 mg

69

7.418,88

7.419

2379 0000777640781 P RUSDI

02164 28/04/2016 Carbamazepine 200 mg

46

14.425,60

17.664

23

3.238,40

12

6.635,52

Risperidon 2 mg

46

59.351,04

Klobazam 10 mg

23

26.496,00

12

1.305,60

Concor 2,5 mg

23

21.962,24

Novorapid Flexpen 100 UI/ml

Miniaspi 80 mg

23

Micardis 80 mg

23 191.360,00

Lantus Solostar 100 UI/ml

2 214.200,00

Vitamin B6 10 mg
2380 0001535260555 P SUPRIATI

2381 0001292062871 P UMMI KULSUM

2382 0002048070339 P KAMARIYAH

02182 28/04/2016 Nopres 20 mg

02183 28/04/2016 Furosemide 40 mg

02184 28/04/2016 Nopres 20 mg

2383 0000116939182 P HJ. SUFIATI

1.078.393

6 645.208,20
4.357,12

23

12.718,08

23

6.300,16

02187 28/04/2016 Lisinopril 10 mg

23

17.664,00

Gliclazide 60 mg

23 161.920,00

Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

Alprazolam 0,5 mg

92.483

19.018

199.235

2384 0000116990943 P SUBROTO

02188 28/04/2016 Novorapid Flexpen 100 UI/ml

3 322.604,10

322.604

2385 0001304389405 P NOVITA ADHIYANTI

02189 28/04/2016 Seretide Diskus 100 100 mcg/puff

1 127.049,58

127.050

2386 0001048493327 A WARDATUL LAILIYAH

02199 28/04/2016 Thyrozol 10 mg

23

33.414,40

33.414

2387 0001819659925 P MOH.BAHRI

02200 28/04/2016 Risperidon 2 mg

46

59.351,04

179.977

Depakote ER 250 mg

23

82.225,92

Clorilex 100 100 mg

38.400,00

12

3.287,04

12

76.800,00

23

16.574,72

46

3.827,20

2388 0002047548159 P PUTRI ANDITA

02201 28/04/2016 Alprazolam 0,5 mg


Clorilex 100 100 mg

2389 0001302820929 P QURROTUL AINI

02205 28/04/2016 Thyrozol 5 mg


Propranolol 10 mg

Halaman :

178

80.087

20.402

No.

No Ka Peserta

Nama

2390 0000774977242 P JUHAIRIYAH

No
Rsp

Tgl Pel

Nama Obat

02206 28/04/2016 Thyrozol 10 mg


Propranolol 10 mg

Jml
R/N Obt
N

23

33.414,40

23

1.913,60

2391 0000117109719 P MASQUFAH

02208 28/04/2016 Symbicort 160/4.5mcg

2392 0001884161349 P A.ZAINI

02209 28/04/2016 Miniaspi 80 mg

Lisinopril 10 mg

2393 0000160642539 P RUSDARWATI

2395 0001291903301 P AGUSTINA SAID


WACHDIN
2396 0001078990659 P MAISARA

35.328

148.176

23

4.357,12

47.634

23

17.664,00

Bisoprolol 5 mg

23

18.988,80

Metformin 500 mg

46

6.624,00

02211 28/04/2016 Amlodipine 10 mg

23

9.715,20

23

17.664,00

02214 28/04/2016 Novorapid Flexpen 100 UI/ml

27.379

2 215.069,40

Seretide Diskus 250 250 mcg/puff

1 142.799,58

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

Lantus Solostar 100 UI/ml

2 214.200,00

02218 28/04/2016 Micardis 80 mg

23 191.360,00

191.360

02219 28/04/2016 Thyrozol 10 mg

60

87.168,00

91.962

35

4.793,60

23

12.835,84

69

9.936,00

Propranolol 40 mg
2397 0001048521521 P HADIRI

Harga
Diajukan

1 148.176,00

Lisinopril 10 mg
2394 0000116949262 I SITI ROCHYATIN

Harga
Obat

02223 28/04/2016 Glimepiride 2 mg


Metformin 500 mg

593.899

22.772

2398 0002035567901 P RAMLAH

02225 28/04/2016 Glimepiride 4 mg

23

12.659,20

12.659

2399 0001094450049 S WIJAYAR

02227 28/04/2016 Allopurinol 300 mg

23

5.873,28

10.849

Simvastatin 10 mg

23

4.975,36

23 191.360,00

46

2400 0000117130533 P BAHRI

02230 28/04/2016 Micardis 80 mg


Metformin 500 mg

197.984

6.624,00

2401 0000117121522 P LIEN CHAJATI

02231 28/04/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

215.069

2402 0000117032681 P NANIK SUGIARTI

02232 28/04/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

329.885

23 114.816,00

23

23 191.360,00

Micardis 40 mg
2403 0000196279885 I HATIMAH

02233 28/04/2016 Gemfibrozil 300 mg


Micardis 80 mg

Halaman :

179

8.508,16

199.868

No.

No Ka Peserta

Nama

2404 0001470262015 P ROFIDAH

2405 0000117087085 P PURWANTO

2406 0000775225102 P MUHABBAH

2407 0000116880478 I SITI MARFU'AH

No
Rsp

Tgl Pel

Nama Obat

02238 28/04/2016 Bisoprolol 5 mg

2409 0000116795799 P ABD RAHMAN

2410 0000117010146 P SAMAN

2411 0000777193727 P SUTIAH

23

18.988,80

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

69 132.480,00

Sifrol ER 375 mcg

23 211.968,00

02270 29/04/2016 Akarbose 100 mg

46

58.291,20

Glimepiride 4 mg

23

12.659,20

Metformin 500 mg

69

9.936,00

02282 29/04/2016 Amlodipine 10 mg

23

9.715,20

23

10.304,00

23

11.893,76

Metformin 500 mg

69

9.936,00

Allopurinol 100 mg

23

2.531,84

23

18.988,80

Ramipril 5 mg

23

17.075,20

Metformin 500 mg

69

9.936,00

Glimepiride 1 mg

23

7.801,60

Clopidogrel 75 mg

23 100.096,00

02290 29/04/2016 Amlodipine 10 mg

23

9.715,20

Lisinopril 10 mg

23

17.664,00

Symbicort 160/4.5mcg

02244 29/04/2016 Levopar 125 mg komb

02283 29/04/2016 Glimepiride 3 mg

02289 29/04/2016 Bisoprolol 5 mg

02291 29/04/2016 Amlodipine 10 mg


Lisinopril 10 mg

2412 0001266925847 P MOH.MANSUR

Harga
Obat

Lisinopril 5 mg
2408 0001410087082 P MUNAMI

Jml
R/N Obt

02292 29/04/2016 Novorapid Flexpen 100 UI/ml


Lantus Solostar 100 UI/ml

23

9.715,20

23

17.664,00

24.362

153.898

175.555

27.379

1 107.100,00
1 148.176,00

148.176
5.663

02294 29/04/2016 Miniaspi 80 mg

23

4.357,12

12

1.305,60

46

14.425,60

180

20.019

2414 0000775233044 P DEWI MAHYATUL ULFA

Halaman :

80.886

3 322.604,10

02295 29/04/2016 Carbamazepine 200 mg

344.448

02293 29/04/2016 Symbicort 160/4.5mcg

2415 0000776047612 P RIZA UMAMI

41.584

1 148.176,00

2413 0000770597133 P MAT SAFI

Furosemide 40 mg

Harga
Diajukan

429.704

29.411

No.

No Ka Peserta

Nama

2416 0000777765688 P SAHEMAH

No
Rsp

Tgl Pel

Nama Obat

23

3.238,40

Phenytoin 100 mg

69

11.746,56

23

17.664,00

23

9.715,20

23

11.893,76

69

9.936,00

23

4.357,12

Isosorbid Dinitrat 5 mg

69

7.772,16

Furosemide 40 mg

69

7.507,20

23

33.414,40

23

1.913,60

02296 29/04/2016 Lisinopril 10 mg

02297 29/04/2016 Glimepiride 3 mg


Metformin 500 mg

2418 0001291432138 P SYAMSIYAH

2419 0001885775962 P KHUSNUL KHATIMAH

02299 29/04/2016 Miniaspi 80 mg

02305 29/04/2016 Thyrozol 10 mg


Propranolol 10 mg

2420 0001868440252 I KURRATUL AINI

02306 29/04/2016 Seretide Diskus 250 250 mcg/puff

2421 0001048572663 P SURIMA

02308 29/04/2016 Glimepiride 4 mg

2424 0001901994625 P YUDI EKO SARI

27.379

21.830

19.636

35.328

142.800

23

12.659,20

22.595

69

9.936,00

23

33.414,40

23

1.913,60

69 132.480,00

Sifrol ER 375 mcg

23 211.968,00

02328 30/04/2016 Vitamin B6 10 mg

23

3.238,40

Phenytoin 100 mg

69

11.746,56

02311 30/04/2016 Thyrozol 10 mg


Propranolol 10 mg

2423 0000117094509 P SAUDATUL MAFRUHAH

Harga
Diajukan

1 142.799,58

Metformin 500 mg
2422 0000774634961 P MAHMUD

Harga
Obat

Vitamin B6 10 mg

Amlodipine 10 mg
2417 0002005785821 P JUWEIRIYEH

Jml
R/N Obt

02320 30/04/2016 Levopar 125 mg komb

35.328

344.448

14.985

2425 0000117092968 P MOHAMMAD BADWI

02334 30/04/2016 Clorilex 100 100 mg

11

70.400,00

70.400

2426 0001268393242 P FATHORRAHMAN

02340 30/04/2016 Micardis 80 mg

23 191.360,00

222.566

Amlodipine 10 mg

23

9.715,20

Bisoprolol 5 mg

23

18.988,80

Furosemide 40 mg

23

2.502,40

02344 30/04/2016 Amlodipine 10 mg

23

9.715,20

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

02345 30/04/2016 Amlodipine 10 mg

23

9.715,20

2427 0000116981188 P AMANIYAH

2428 0000116827852 P MOH ZAINI

Halaman :

181

31.545

31.545

No.

No Ka Peserta

Nama

2429 0000774578654 P NUR FADILAH

No
Rsp

Tgl Pel

Nama Obat

2431 0000116984687 P MOHAMMAD PANJAR

2432 0001410112765 P ZAINULLAH

Harga
Obat

Glimepiride 3 mg

23

11.893,76

Metformin 500 mg

69

9.936,00

02347 30/04/2016 Alprazolam 0,5 mg

23

6.300,16

46 379.776,00

69

7.772,16

Lisinopril 10 mg

23

17.664,00

Gemfibrozil 300 mg

23

8.508,16

Clopidogrel 75 mg

23 100.096,00

3 322.604,10

Olandoz 5 5 mg
2430 0001807610196 P HASANAH

Jml
R/N Obt

02348 30/04/2016 Isosorbid Dinitrat 5 mg

02349 30/04/2016 Novorapid Flexpen 100 UI/ml


Allopurinol 300 mg

Lantus Solostar 100 UI/ml

02350 30/04/2016 Thyrozol 10 mg

23

Harga
Diajukan

386.076

134.040

435.577

5.873,28

1 107.100,00

39

56.659,20

Propranolol 10 mg

69

5.740,80

2433 0000116934311 P DRS.MOH.KADIR

02355 30/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

2434 0000116986329 P SITI HUZAIMAH

02356 30/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

2435 0000116954076 P MUNI AH JD. ATMAWI

02357 30/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

2436 0001105167497 P TUPUN

02368 30/04/2016 Lisinopril 10 mg

23

17.664,00

17.664

2437 0001410416177 P FATHOR RAHMAN

02369 30/04/2016 Clorilex 100 100 mg

11

70.400,00

70.400

2438 0000117047294 I HJ. RUSTINI

02371 30/04/2016 Glicab 80 mg

23

6.947,84

26.599

Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

02372 30/04/2016 Amlodipine 10 mg

23

9.715,20

Metformin 500 mg

69

9.936,00

Glimepiride 4 mg

23

12.659,20

2439 0000117020744 I SITI HASANAH

2440 0000172349785 1 IRA ANGGRAINI

02373 30/04/2016 Seretide Diskus 250 250 mcg/puff

2441 0000117129914 P DINA AINUN

02376 30/04/2016 Gemfibrozil 300 mg

2442 0000117131229 P TOHARI

02377 30/04/2016 Akarbose 100 mg

Halaman :

182

Novomix Flexpen 100 UI/ml

Metformin 500 mg

62.400

32.310

1 142.799,58

142.800

23

8.508,16

8.508

23

29.145,60

306.202

2 267.120,00
69

9.936,00

No.

No Ka Peserta

Nama

2443 0000117131117 P MOHAMMAD ANSHARI

2444 0000117130972 P DIDIK ATRAWI

No
Rsp

Tgl Pel

Nama Obat

02378 30/04/2016 Gemfibrozil 300 mg

Harga
Obat

23

8.508,16

Metformin 500 mg

69

9.936,00

Lantus Solostar 100 UI/ml

02379 30/04/2016 Lisinopril 10 mg

23

17.664,00

Metformin 500 mg

69

9.936,00

23

9.715,20

Lantus Solostar 100 UI/ml


02381 30/04/2016 Miniaspi 80 mg
Isosorbid Dinitrat 5 mg

3 322.604,10

1 107.100,00

23

4.357,12

69

7.772,16

02382 30/04/2016 Lantus Solostar 100 UI/ml

2448 0000116925614 I WAKIATUN

02383 30/04/2016 Amlodipine 10 mg

Lisinopril 10 mg

125.544

134.700

1 107.100,00

2447 0000116976936 I MAIMUNAH

Harga
Diajukan

1 107.100,00

Lantus Solostar 100 UI/ml

2445 0001126067411 P AHMAD JUFRI SETIAWAN 02380 30/04/2016 Amlodipine 10 mg


HADI
Novorapid Flexpen 100 UI/ml

2446 0000116928369 P ACH.SUWANDI

Jml
R/N Obt

439.419

12.129

1 107.100,00

107.100

23

9.715,20

27.379

23

17.664,00

2449 0000772624089 P PUSIHA

02384 30/04/2016 Amlodipine 10 mg

23

9.715,20

9.715

2450 0000778319021 P HANIFAH

02386 30/04/2016 Spironolacton 25 mg

23

9.273,60

11.776

23

2.502,40

Furosemide 40 mg
2451 0001434124787 P TINIYATUN

02387 30/04/2016 Seretide Diskus 250 250 mcg/puff

2452 0000776982339 P SUMA'AH

02388 30/04/2016 Miniaspi 80 mg

N
N

Spironolacton 25 mg

1 142.799,58

142.800

23

4.357,12

13.631

23

9.273,60

2453 0001048553109 P DESI ANDRIANI PAUSI

02389 30/04/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2454 0001859563596 P NURIYAMI

02390 30/04/2016 Novorapid Flexpen 100 UI/ml

2 215.069,40

322.169

1 107.100,00

Lantus Solostar 100 UI/ml


2455 0001793955497 P MOH.HASAN

2456 0000116945807 P MOCH. SADALI

Halaman :

183

02391 30/04/2016 Amlodipine 10 mg

23

Micardis 80 mg

23 191.360,00

00018 02/05/2016 Miniaspi 80 mg

23

Diovan 80 mg

23 114.816,00

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

9.715,20

4.357,12

201.075

130.949

No.

No Ka Peserta

Nama

No
Rsp

Tgl Pel

Jml
R/N Obt

Nama Obat

Harga
Obat

Harga
Diajukan

2457 0001048518292 P TITIK WAHYUNI

00021 02/05/2016 Glimepiride 3 mg

23

11.893,76

11.894

2458 0000116977274 P ABOEBAKAR

00026 02/05/2016 Alprazolam 1 mg

23

6.859,52

6.860

2459 0000117065608 I MIYATI

00034 02/05/2016 Lisinopril 10 mg

23

17.664,00

29.293

Glimepiride 1 mg

23

7.801,60

Propranolol 10 mg

46

3.827,20

46

14.425,60

R.01 11,5

17.664,00

2460 0001295679982 P HAIKAL BARIO

00037 02/05/2016 Carbamazepine 200 mg


Risperidon 1 mg

2461 0000199560194 P HAWARI

00039 02/05/2016 Bisoprolol 5 mg

23

18.988,80

Lisinopril 5 mg

23

10.304,00

Spironolacton 25 mg

23

9.273,60

Furosemide 40 mg

23

2.502,40

2462 0000117129341 P ASPA BISAPA

00043 02/05/2016 Seretide Diskus 250 250 mcg/puff

2463 0000166164917 P ANDYKA BUDIHARTO

00048 02/05/2016 Merlopam 2 mg

Risperidon 2 mg
Clorilex 100 100 mg
2464 0000116910797 P MENA JD.II
SANGNGARAN

00050 02/05/2016 Glimepiride 3 mg


Metformin 500 mg

2465 0000777977605 P RIFAIE

00066 02/05/2016 Thyrozol 10 mg


Propranolol 10 mg

32.090

41.069

1 142.799,58

142.800

12

20.597,76

156.749

46

59.351,04

12

76.800,00

23

11.893,76

69

9.936,00

23

33.414,40

23

1.913,60

21.830

35.328

2466 0000117061784 P MOH SUGIANTO

00067 02/05/2016 Seretide Diskus 250 250 mcg/puff

1 142.799,58

142.800

2467 0000778262984 P SITTIHA

00068 02/05/2016 Novorapid Flexpen 100 UI/ml

6 645.208,20

859.408

Lantus Solostar 100 UI/ml

2 214.200,00

00071 02/05/2016 Lantus Solostar 100 UI/ml

1 107.100,00

2468 0001306752748 P LATIFAH

Total :

356.711.057,0

Menyetujui,

Halaman :

184

107.100

No.

No Ka Peserta

Halaman :

185

Nama

No
Rsp

Tgl Pel

Nama Obat

Jml
R/N Obt

Harga
Obat

Harga
Diajukan