Medicare AdvantagePrior AuthMedium impact
Valstar (valrubicin) (Revised)
Humana·FL, KY, SC, VA · Oncology, Urology·Medicaid
Effective date
Jan 1, 2021
We identified it
Jun 25, 2026
Summary
This is a revised Humana prior authorization policy for Valstar (valrubicin) intravesical therapy effective January 1, 2021, with a revision date of February 25, 2026. The policy covers BCG-refractory carcinoma in situ of the urinary bladder for Medicare and four state Medicaid programs (Florida, Kentucky, South Carolina, Virginia). Prior authorization is required; claims must meet three clinical criteria and have no active exclusions to be approved.
Action Required
Before submitting any Valstar (valrubicin) claims for Medicaid or Medicare members: (1) Billing team must verify prior authorization requirements in billing software for all Valstar/valrubicin intravesical solution claims. (2) Prior to claim submission, ensure clinical documentation from ordering provider demonstrates: member has recurrent/persistent carcinoma in situ (CIS) of urinary bladder; member has experienced BCG therapy failure (progression, intolerance, or contraindication); member is NOT a candidate for immediate cystectomy. (3) Verify member does NOT have active UTI, perforated/compromised bladder, or small bladder capacity (unable to tolerate 75 mL instillation). (4) Submit prior authorization request through Humana's PAL system at www.humana.com/PAL using appropriate medical procedure codes before dispensing medication. (5) Do not process claims without documented prior authorization approval. Failure to obtain prior authorization will result in claim denials. (6) For claim coding, visit www.humana.com/PAL to obtain applicable preauthorization and notification lists with correct medical billing codes.