Definitions

7. As used in sections 7 through 10 of this act: "Covered person" means a person on whose behalf the State Health Benefits Program or the School Employees' Health Benefits Program is obligated to pay benefits or provide services pursuant to the health benefits plan. "Health benefits plan" means a plan providing health care benefits coverage for public employees and their dependents offered by the State Health Benefits Program or the School Employees' Health Benefits Program. "Health care provider" means an individual or entity which, acting within the scope of its licensure or certification, provides a covered service defined by the health benefits plan. Health care provider includes, but is not limited to, a physician and other health care professionals licensed pursuant to Title 45 of the Revised Statutes and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes. "Medical necessity" or "medically necessary" means the same as those terms are defined in section 4 of P.L.2023, c.296 (C.17B:30-55.3). "Step therapy exception" means the overriding of a step therapy protocol in favor of immediate coverage of the health care provider's selected prescription drug. "Step therapy protocol" means a protocol, policy, or program that establishes the specific sequence in which prescription drugs for a specified medical condition, and medically appropriate for a particular patient, are required to be administered in order to be covered by a health benefits plan. "Utilization review organization" means an entity that contracts with a vendor to conduct utilization review. "Vendor" means a third-party administrator that conducts claims administration, network management, claims processing, or other related services for the State Health Benefits Commission or the School Employees' Health Benefits Commission.