Medicare AdvantageCoverageHigh impact
Coverage changes for Stelara and biosimilars
Harvard Pilgrim Health Care·RI · Rheumatology, Dermatology, Gastroenterology +2 more·Pharmacy
Effective date
Nov 1, 2025
We identified it
Jun 26, 2026
Summary
Effective November 1, 2025, Tufts Health RITogether will shift coverage for ustekinumab (Stelara) biosimilars. Yesintek will become the preferred formulary option requiring prior authorization, while Stelara and all other FDA-approved biosimilars will become non-preferred and non-formulary. Patients currently on Stelara can transition to Yesintek without a new prior authorization, but providers should issue new prescriptions to facilitate the change.
Action Required
By October 31, 2025: Billing team must update billing system workflows to recognize Yesintek as preferred formulary for Tufts Health RITogether members effective Nov. 1, 2025, requiring prior authorization before claim submission. Update pharmacy verification protocols and insurance eligibility checks to flag Stelara as non-covered for this plan. Clinical staff should identify all active Tufts RITogether patients currently prescribed Stelara and coordinate with providers to issue new prescriptions for Yesintek. Although existing patients do not require new prior authorization, resubmit any pending Stelara claims as Yesintek to prevent denials. Failure to transition billing to Yesintek will result in claim denials for Stelara prescriptions after the effective date.