Mitosol

Generic: mitomycin

2MG — Kit

Ophthalmic Agents, Other

Also known as: MITOSOL KIT .2MG mitomycin
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 14 hours, 53 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Signature Gold with Atrium Health + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Streamlined Silver with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Streamlined Silver
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold with Atrium Health
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold with Atrium Health + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Streamlined Silver with Atrium Health
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Streamlined Silver
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Mutamycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 14 hours, 53 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 14 hours, 53 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
AIAN Cost Share
via mitomycin 		Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via mitomycin 		Tier 2 - Generic — — — None
Silver Classic
via mitomycin 		Tier 2 - Generic — — — None
Secure
via mitomycin 		Tier 2 - Generic — — — None
Bronze Classic 4700
via mitomycin 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via mitomycin 		Tier 2 - Generic — — — None
Gold Elite Saver Plus
via mitomycin 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via mitomycin 		Tier 2 - Generic — — — None
Bronze Classic Standard
via mitomycin 		Tier 2 - Generic — — — None
Silver Classic Standard
via mitomycin 		Tier 2 - Generic — — — None
Gold Classic Standard
via mitomycin 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 14 hours, 53 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
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