Mutamycin

Generic: mitomycin

20 MG

Alkylating Drug

Also known as: 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: 16 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver
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
Standard Expanded Bronze + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug 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
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard 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
Standard Expanded Bronze with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 16 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via Mitosol 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Mitosol 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026
via Mitosol 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 16 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via Mitosol 		Tier 4 - Higher Cost — — — None
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