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., personcode "01", relationshipcode "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

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](dur-alerts.md) and produces a claim with appropriate DUR response.

Cohort Skills

Load the appropriate cohort based on user request:

Generation Parameters

Output Entities

RxMember

Pharmacy member/cardholder information:

• memberid, cardholderid
• bin, pcn, groupnumber, personcode
• rxplancode, coverage_start/end
• relationshipcode, subscriberid
• mailordereligible, specialty_eligible

RxPlan

Pharmacy benefit plan configuration:

• rxplancode, planname, plantype
• formularyid, tierstructure
• rxdeductible, rxoop_max
• specialty settings (coinsurance, per-fill max)
• Part D phases (for Medicare plans)

RxAccumulator

Pharmacy benefit accumulators:

• rx_deductible (applied, limit, remaining)
• rxoopmax (applied, limit, remaining)
• specialtyoop, dawbrand_penalty
• TrOOP (for Medicare Part D)
• current_phase (for Part D)

Prescription

Written prescription details:

• prescriptionnumber, ndc, drugname
• quantityprescribed, dayssupply
• refillsauthorized, refillsremaining
• prescribernpi, prescriberdea
• writtendate, expirationdate
• daw_code, directions

PharmacyClaim

NCPDP-style claim transaction:

• claimid, transactioncode (B1/B2/B3)
• bin, pcn, groupnumber, cardholderid
• pharmacynpi, prescribernpi
• ndc, quantitydispensed, dayssupply
• pricing fields (ingredient cost, dispensing fee)
• DUR fields (reason, service, result codes)

ClaimResponse

Adjudication response:

• transactionresponsestatus (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:

• paid, status, patype
• requestdate, decisiondate
• approval details (override_code, expiration)
• denial details (reason, alternatives)
• clinical information, urgency

DURAlert

Drug utilization review alert:

• durcode, durtype, clinical_significance
• interactingdrugs, severitylevel
• overridecode, outcomecode
• pharmacist_message, recommendation

FormularyDrug

Drug coverage information:

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

CopayAssistance

Manufacturer copay programs:

• programid, programtype
• ndc, program_name
• annualmaxbenefit, remaining_benefit
• copaycovered, effectivedates

See [../../references/data-models.md](../../references/data-models.md) for complete schemas.

NCPDP Transaction Codes

Common Reject Codes

DUR Alert Types

Output Formats

See [../../formats/ncpdp-d0.md](../../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:

PatientSim Cohort Links: [diabetes-management](../patientsim/diabetes-management.md), [heart-failure](../patientsim/heart-failure.md), [chronic-kidney-disease](../patientsim/chronic-kidney-disease.md), [behavioral-health](../patientsim/behavioral-health.md), [oncology](../patientsim/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:

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](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:

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

Reference Data

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

Generative Framework Integration

RxMemberSim integrates with the [Generative Framework](../generation/SKILL.md) 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](../generation/executors/cross-domain-sync.md).