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: 14 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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
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
Standard Silver with Atrium Health
via mitomycin 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health
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 Gold with Atrium Health + Vision + Adult Dental
via mitomycin 		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
Elite Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental 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
Complete Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded 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
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 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
Complete Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday 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
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 14 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 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 - 80/20 Plus PPO 2026
via Mitosol 		Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 14 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Simple Chronic Care CKM | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | 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
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
Silver Simple Diabetes | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
Gold Elite Saver Plus | 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
Gold Classic Standard | 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
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 PCP Saver | with Atrium Health
via mitomycin 		Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health
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
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 14 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Silver Standard (No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Gold Standard (No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Bronze Standard (No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Mitosol 		Tier 4 - Non-Preferred — — — None
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