CommercialPrior AuthHigh impact
Pharmacy coverage changes
Harvard Pilgrim Health Care·RI · Pharmacy, Rheumatology, Gastroenterology +1 more·Pharmacy
Effective date
Oct 1, 2026
We identified it
Aug 1, 2026
Summary
Effective 10/1/2026, Yesintek (ustekinumab-kfce) will be removed from formulary and become non-covered for Tufts Health RITogether plans. Starjemza (ustekinumab-hmny), the preferred ustekinumab biosimilar, will replace it and require prior authorization. New starts and new members will have coverage reviewed under different medical necessity guidelines.
Action Required
By September 1, 2026: Billing and clinical teams must implement the following changes for Tufts Health RITogether members: (1) Stop billing for Yesintek as a covered medication; (2) Update pharmacy benefit management system to flag Yesintek as non-formulary; (3) Configure system to require prior authorization for Starjemza claims using the Targeted Immunomodulators Self-administration MNG criteria; (4) For existing patients on Yesintek, coordinate with providers and members to transition to Starjemza with prior auth obtained before 10/1/26; (5) For new starts or new members, ensure prior authorization is obtained before dispensing Starjemza using the appropriate medical necessity guidelines. Failure to obtain prior authorization will result in claim denials and potential member out-of-pocket costs. Reference the Pharmacy Medical Necessity Guidelines page on Point32Health provider website for specific authorization criteria.