CurrentCareSourcePolicy N/A

UTILIZATION MANAGEMENT MEDICAL POLICY

Defines prior authorization recommendations, coverage criteria, dosing limits, and exclusions for medical-benefit valrubicin (Valstare) for intravesical treatment of BCG-refractory carcinoma in situ of the urinary bladder.

Policy Summary

PayerCareSource

PolicyUTILIZATION MANAGEMENT MEDICAL POLICY

Policy CodePolicy N/A

Change TypeAnnual Revision (No criteria changes)

Effective Date

Next Review Date

Key ActionPrior Authorization is recommended; approve only if criteria and dosing are met and refer doses outside policy to clinician review.

SourceLink

POLICY UPDATE CHANGES

Annual Revision, Summary of Changes = No criteria changes.

1Covered Indications

ValrubicinDrug addressed

2 monthsInitial Approval Duration

Coverage Summary

Covered with criteria: intravesical valrubicin (Valstare) for BCG‑refractory carcinoma in situ (CIS) of the urinary bladder when immediate cystectomy would have unacceptable morbidity or mortality, per the FDA‑approved indication. NCCN (Bladder Cancer Clinical Practice Guidelines, version 5.2024, Oct 28, 2024) recommends intravesical valrubicin for BCG‑refractory CIS and as an option during BCG shortages. Authorization follows the policy criteria and dosing limits.