RxMemberSim - Pharmacy and PBM Data Generation

For Claude

Use this skill when the user requests pharmacy data, prescription fills, or PBM cohorts. Load the cohort sub-skill from the Cohort Skills table for specific scenarios.

Triggers: prescriptions, pharmacy claims, medication fills, DUR alerts, drug interactions, formulary/tier cohorts, NCPDP output, pharmacy prior authorization, step therapy

Capabilities: pharmacy members (BIN/PCN/Group), prescription fills with NDC codes, claim adjudication and pricing, DUR alerts, formulary/tier management, manufacturer copay programs, NCPDP D.0 output

Safety Guardrails

• All data is synthetic. Every member, claim, NDC, NPI, and pricing value is fabricated. Never present output as real patient or pharmacy data.
• No clinical advice. RxMemberSim models PBM workflows only. Decline real drug recommendations or dosing guidance; refer users to a licensed pharmacist.
• No real PHI. Never embed real patient identifiers, DEA numbers, or actual cardholder IDs. Use realistic but fictional values.
• NDC codes are illustrative. Example NDCs approximate real formats but may not map to FDA-registered products. Validate against the FDA NDC Directory for production use.
• Pricing is synthetic. Ingredient costs, dispensing fees, and copay amounts do not reflect actual AWP, WAC, or MAC pricing.

Edge Cases and Validation

• Missing NDC or drug name: Generate a plausible synthetic NDC (11-digit 5-4-2 format) and map to a fictional drug. Never leave NDC blank.
• Invalid BIN/PCN/Group: Flag as rejected with reject code 99 ("Host Processing Error") and include a corrective message.
• Partial member data: Fill missing fields with realistic defaults (e.g., person_code "01", relationship_code "1" for subscriber). Note which fields were defaulted.
• Unknown RxNorm or GPI code: Use a synthetic code in the correct format. Note that production systems should validate against the RxNorm API or GPI reference.
• Negative examples — do NOT generate: real DEA numbers, actual AWP/WAC pricing, clinical dosing recommendations, or data presented as non-synthetic.

Pharmacy Code Systems

System	Use	Example
NDC	Drug product identifier (11-digit)	00071015523
RxNorm	Standard drug concept (ingredient, dose form)	RxCUI 83367
GPI	Generic Product Identifier (drug class hierarchy)	39400010100310
NCPDP	Pharmacy identifier and transaction standard	D.0 format
NPI	Provider/pharmacy identifier	1234567890
ICD-10-CM	Diagnosis code (required for PA submissions)	E11.9
HCPCS	Medical pharmacy / buy-and-bill drugs	J0135

Quick Start

Simple Pharmacy Claim

Request: "Generate a pharmacy claim for atorvastatin"

{
  "claim": {
    "claim_id": "RX20250115000001",
    "transaction_code": "B1",
    "service_date": "2025-01-15",
    "ndc": "00071015523",
    "drug_name": "Atorvastatin 20mg",
    "quantity": 30,
    "days_supply": 30,
    "pharmacy_npi": "1234567890"
  },
  "response": {
    "status": "paid",
    "ingredient_cost": 12.50,
    "dispensing_fee": 2.00,
    "copay": 10.00,
    "plan_paid": 4.50
  }
}

DUR Alert Cohort

Request: "Generate a pharmacy claim that triggers a drug interaction alert"

Claude loads dur-alerts.md and produces a claim with appropriate DUR response.

Cohort Skills

Load the appropriate cohort based on user request:

Cohort	Trigger Phrases	File
Retail Pharmacy	prescription, fill, refill, copay, retail	retail-pharmacy.md
Specialty Pharmacy	specialty drug, biologics, limited distribution	specialty-pharmacy.md
DUR Alerts	drug interaction, DUR, therapeutic dup, early refill	dur-alerts.md
Formulary Management	formulary, tier, coverage, preferred	formulary-management.md
Rx Enrollment	rx enrollment, pharmacy member, BIN PCN, rx coverage	rx-enrollment.md
Rx Prior Auth	rx prior auth, pharmacy PA, step therapy, formulary exception	rx-prior-auth.md
Rx Accumulators	rx accumulator, pharmacy deductible, rx OOP, TrOOP, Part D phase	rx-accumulator.md
Manufacturer Programs	copay card, PAP, patient assistance, copay assistance, hub program	manufacturer-programs.md

Generation Parameters

Parameter	Type	Default	Description
fill_type	string	new	new, refill
drug_type	string	generic	generic, brand, specialty
pharmacy_type	string	retail	retail, mail_order, specialty
claim_status	string	paid	paid, rejected, reversed
dur_outcome	string	none	none, warning, reject

Output Entities

RxMember

Pharmacy member/cardholder information:

• member_id, cardholder_id
• bin, pcn, group_number, person_code
• rx_plan_code, coverage_start/end
• relationship_code, subscriber_id
• mail_order_eligible, specialty_eligible

RxPlan

Pharmacy benefit plan configuration:

• rx_plan_code, plan_name, plan_type
• formulary_id, tier_structure
• rx_deductible, rx_oop_max
• specialty settings (coinsurance, per-fill max)
• Part D phases (for Medicare plans)

RxAccumulator

Pharmacy benefit accumulators:

• rx_deductible (applied, limit, remaining)
• rx_oop_max (applied, limit, remaining)
• specialty_oop, daw_brand_penalty
• TrOOP (for Medicare Part D)
• current_phase (for Part D)

Prescription

Written prescription details:

• prescription_number, ndc, drug_name
• quantity_prescribed, days_supply
• refills_authorized, refills_remaining
• prescriber_npi, prescriber_dea
• written_date, expiration_date
• daw_code, directions

PharmacyClaim

NCPDP-style claim transaction:

• claim_id, transaction_code (B1/B2/B3)
• bin, pcn, group_number, cardholder_id
• pharmacy_npi, prescriber_npi
• ndc, quantity_dispensed, days_supply
• pricing fields (ingredient cost, dispensing fee)
• DUR fields (reason, service, result codes)

ClaimResponse

Adjudication response:

• transaction_response_status (A, R, P, D)
• pricing (ingredient cost paid, dispensing fee, patient pay)
• reject codes (if applicable)
• DUR alerts (if applicable)
• authorization number, accumulated amounts

PharmacyPriorAuth

Pharmacy PA request and decision:

• pa_id, status, pa_type
• request_date, decision_date
• approval details (override_code, expiration)
• denial details (reason, alternatives)
• clinical information, urgency

DURAlert

Drug utilization review alert:

• dur_code, dur_type, clinical_significance
• interacting_drugs, severity_level
• override_code, outcome_code
• pharmacist_message, recommendation

FormularyDrug

Drug coverage information:

• ndc, gpi, rxnorm_code, drug_name
• tier, covered status
• PA required, step therapy required
• quantity limits, age/gender restrictions

CopayAssistance

Manufacturer copay programs:

• program_id, program_type
• ndc, program_name
• annual_max_benefit, remaining_benefit
• copay_covered, effective_dates

See ../../references/data-models.md for complete schemas.

NCPDP Transaction Codes

Code	Description	Use Case
B1	Billing	New claim submission
B2	Reversal	Cancel previous claim
B3	Rebill	Correct and resubmit
E1	Eligibility	Check coverage
P1	Prior Auth Request	Submit PA
P2	Prior Auth Inquiry	Check PA status
P4	Prior Auth Cancel	Cancel PA request

Common Reject Codes

Code	Description	Resolution
70	Product/Service Not Covered	Check formulary, PA
75	Prior Authorization Required	Submit PA request
76	Plan Limitations Exceeded	Check quantity limits
79	Refill Too Soon	Wait or override
80	Prescriber Not Found	Verify NPI
83	Duplicate Paid Claim	Check claim history
88	DUR Reject	Clinical review needed

DUR Alert Types

Code	Type	Description
DD	Drug-Drug	Interaction between medications
TD	Therapeutic Duplication	Same drug class
ER	Early Refill	Before 80% supply used
HD	High Dose	Exceeds recommended dose
LD	Low Dose	Below therapeutic dose
DA	Drug-Age	Age precaution
DG	Drug-Gender	Gender precaution
DC	Drug-Disease	Contraindication

Output Formats

Format	Request	Use Case
JSON	default	API testing
NCPDP D.0	"as NCPDP", "pharmacy claim format"	Real-time claims
CSV	"as CSV"	Analytics

See ../../formats/ncpdp-d0.md for transformation.

Examples

Example 1: Generic Fill - Paid

Request: "Generate a paid pharmacy claim for lisinopril"

{
  "claim": {
    "claim_id": "RX20250115000001",
    "transaction_code": "B1",
    "service_date": "2025-01-15",
    "bin": "610014", "pcn": "RXGROUP", "group_number": "CORP001",
    "cardholder_id": "001234001",
    "ndc": "00093505601",
    "drug_name": "Lisinopril 10mg Tablet",
    "quantity_dispensed": 30,
    "days_supply": 30,
    "pharmacy_npi": "9876543210",
    "prescriber_npi": "1234567890",
    "ingredient_cost_submitted": 8.50,
    "dispensing_fee_submitted": 2.00
  },
  "response": {
    "status": "paid",
    "ingredient_cost_paid": 8.50,
    "dispensing_fee_paid": 1.75,
    "patient_pay_amount": 10.00,
    "copay_amount": 10.00,
    "authorization_number": "AUTH20250115001"
  }
}

Example 2: Brand Drug - Rejected (PA Required)

Request: "Generate a rejected claim for Eliquis requiring prior auth"

{
  "claim": {
    "claim_id": "RX20250115000002",
    "transaction_code": "B1",
    "service_date": "2025-01-15",
    "ndc": "00003089421",
    "drug_name": "Eliquis 5mg Tablet",
    "quantity_dispensed": 60,
    "days_supply": 30
  },
  "response": {
    "status": "rejected",
    "reject_code": "75",
    "reject_message": "Prior Authorization Required",
    "additional_message": "Submit PA with diagnosis and documentation of AFib or VTE",
    "help_desk_phone": "1-800-555-0123"
  }
}

Example 3: Early Refill Warning

Request: "Generate a claim with early refill DUR alert"

{
  "claim": {
    "claim_id": "RX20250115000003",
    "ndc": "00071015523",
    "drug_name": "Atorvastatin 20mg",
    "service_date": "2025-01-15",
    "quantity_dispensed": 30,
    "days_supply": 30
  },
  "response": {
    "status": "paid",
    "dur_response": {
      "alert_count": 1,
      "alerts": [
        {
          "type": "ER",
          "description": "Early Refill",
          "severity": "warning",
          "message": "Refill 8 days early (73% of supply used)",
          "previous_fill_date": "2024-12-27",
          "days_supply_previous": 30,
          "percent_used": 73,
          "professional_service_code": "M0",
          "result_of_service_code": "1A"
        }
      ]
    },
    "patient_pay_amount": 10.00
  }
}

Example 4: Specialty Drug with Copay Assistance

Request: "Generate a specialty pharmacy claim with manufacturer copay card"

{
  "claim": {
    "claim_id": "RX20250115000004",
    "ndc": "00074433906",
    "drug_name": "Humira 40mg/0.4mL Pen",
    "quantity_dispensed": 2,
    "days_supply": 28,
    "pharmacy_type": "specialty"
  },
  "response": {
    "status": "paid",
    "ingredient_cost_paid": 6500.00,
    "dispensing_fee_paid": 0.00,
    "patient_pay_amount": 500.00,
    "coinsurance_amount": 500.00,
    "tier": 5
  },
  "copay_assistance": {
    "program_name": "Humira Complete",
    "program_bin": "004682",
    "copay_card_applied": true,
    "assistance_amount": 495.00,
    "final_patient_pay": 5.00,
    "annual_max_benefit": 16000.00,
    "remaining_benefit": 15505.00
  }
}

Related Skills

Cross-Product: PatientSim (Clinical)

RxMemberSim pharmacy claims correspond to PatientSim medication orders:

RxMemberSim Skill	PatientSim Cohorts	Integration
retail-pharmacy.md	Chronic disease meds, discharge Rx	Fill date +0-3 days from order/discharge
specialty-pharmacy.md	Oncology, biologics	Limited distribution, PA often required
dur-alerts.md	Multi-drug regimens	DDI based on patient's med list
rx-prior-auth.md	High-cost drugs	Clinical criteria from PatientSim

PatientSim Cohort Links: diabetes-management, heart-failure, chronic-kidney-disease, behavioral-health, oncology

Integration Pattern: Generate medication orders in PatientSim, then model fills in RxMemberSim. Match NDCs, apply fill timing (retail: same day; specialty: +1-7 days), and PA rules.

Cross-Product: MemberSim (Claims)

Pharmacy and medical benefits coordinate:

RxMemberSim Skill	MemberSim Skill	Integration
formulary-management.md	plan-benefits.md	Coordinated benefit design
rx-accumulator.md	accumulator-tracking.md	Combined deductible/OOP
rx-prior-auth.md	prior-authorization.md	Pharmacy vs. medical PA
rx-enrollment.md	enrollment-eligibility.md	Synchronized coverage

Integration Pattern: For integrated medical+Rx plans, pharmacy costs count toward combined OOP maximum. Ensure coverage dates and accumulator totals are synchronized.

Cross-Product: PopulationSim Integration

When a geography is specified, RxMemberSim grounds prescribing patterns and adherence in PopulationSim's CDC PLACES, SVI, and ADI data. See populationsim-integration.md for the generation pattern and SDOH impact tables.

Cross-Product: NetworkSim (Pharmacy Networks)

NetworkSim provides pharmacy entities and benefit structures for prescription claims:

RxMemberSim Need	NetworkSim Skill	Generated Entity
Dispensing pharmacy	pharmacy-for-rx.md	Pharmacy with NCPDP, NPI
Formulary context	formulary-for-rx.md	Tier, PA requirements
Pharmacy benefit	synthetic-pharmacy-benefit.md	Benefit design
Specialty pharmacy	specialty-pharmacy.md	Limited distribution, hub model

Integration Pattern: Generate claims in RxMemberSim first, then use NetworkSim to add pharmacy entities with NCPDP IDs and formulary context.

Output Formats

• ../../formats/ncpdp-d0.md - NCPDP D.0 format
• ../../formats/csv.md - CSV export
• ../../formats/sql.md - SQL export

Reference Data

• ../../references/data-models.md - Entity schemas
• ../../references/code-systems.md - NDC, RxNorm, GPI, NCPDP codes

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Generative Framework Integration

RxMemberSim integrates with the Generative Framework for specification-driven generation at scale.

• Profile-Driven: "Generate 200 pharmacy members from the Medicare diabetic profile" — samples demographics, assigns Rx coverage, links to formulary/network.
• Journey-Driven: "Add diabetic first-year journey with fills" — generates Rx, refills, DUR alerts, and accumulator impacts (TrOOP for Part D).
• Cross-Domain Sync: RxMember → MemberSim Member, Fill → PatientSim Prescription, Pharmacy/Prescriber → NetworkSim. See cross-domain-sync.md.