RxMemberSim - Pharmacy and PBM Data Generation

For Claude

Use this skill when the user requests pharmacy data, prescription fills, or PBM (Pharmacy Benefit Management) scenarios. This is the primary skill for generating realistic synthetic pharmacy claims and drug utilization data.

When to apply this skill:

• User mentions prescriptions, pharmacy claims, or medication fills
• User requests DUR (Drug Utilization Review) alerts or drug interactions
• User specifies formulary, tier, or coverage scenarios
• User asks for NCPDP formatted output
• User needs pharmacy prior authorization or step therapy data

Key capabilities:

• Generate pharmacy members with BIN/PCN/Group identifiers
• Create prescription fills (new and refill) with NDC codes
• Model pharmacy claim adjudication and pricing
• Generate DUR alerts (drug interactions, therapeutic duplications, early refills)
• Handle formulary management and tier structures
• Model manufacturer copay programs and patient assistance
• Transform output to NCPDP D.0 format

For specific pharmacy scenarios, load the appropriate scenario skill from the table below.

Overview

RxMemberSim generates realistic synthetic pharmacy data for testing pharmacy benefit management (PBM) systems, claims adjudication, and drug utilization review. This includes:

• Prescription fills (new and refill)
• Pharmacy claims (NCPDP D.0)
• Drug Utilization Review (DUR) alerts
• Formulary and tier management
• Prior authorization workflows
• Manufacturer copay programs

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 Scenario

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

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

Scenario Skills

Load the appropriate scenario based on user request:

Scenario	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, 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"

{
  "member": {
    "member_id": "MEM001234",
    "cardholder_id": "001234001",
    "bin": "610014",
    "pcn": "RXGROUP",
    "group_number": "CORP001"
  },
  "prescription": {
    "prescription_number": "RX78901234",
    "ndc": "00093505601",
    "drug_name": "Lisinopril 10mg Tablet",
    "quantity_prescribed": 30,
    "days_supply": 30,
    "refills_authorized": 5,
    "prescriber_npi": "1234567890",
    "written_date": "2025-01-10"
  },
  "claim": {
    "claim_id": "RX20250115000001",
    "transaction_code": "B1",
    "service_date": "2025-01-15",
    "pharmacy_npi": "9876543210",
    "pharmacy_ncpdp": "1234567",
    "ndc": "00093505601",
    "quantity_dispensed": 30,
    "days_supply": 30,
    "fill_number": 0,
    "daw_code": "0",
    "ingredient_cost_submitted": 8.50,
    "dispensing_fee_submitted": 2.00,
    "usual_customary_charge": 15.00,
    "gross_amount_due": 10.50
  },
  "response": {
    "status": "paid",
    "message": "Claim accepted",
    "ingredient_cost_paid": 8.50,
    "dispensing_fee_paid": 1.75,
    "total_amount_paid": 0.25,
    "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

RxMemberSim Scenarios

• retail-pharmacy.md - Standard retail fills
• specialty-pharmacy.md - Specialty drug distribution
• dur-alerts.md - Drug utilization review
• formulary-management.md - Formulary and tier structure
• rx-enrollment.md - Pharmacy enrollment and eligibility
• rx-prior-auth.md - Pharmacy prior authorization
• rx-accumulator.md - Pharmacy accumulator tracking
• manufacturer-programs.md - Copay cards, PAPs, hub programs

Cross-Product: PatientSim (Clinical)

RxMemberSim pharmacy claims correspond to PatientSim medication orders:

RxMemberSim Skill	PatientSim Scenarios	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 Scenario Links:

• ../patientsim/diabetes-management.md - Oral agents, insulin, GLP-1s
• ../patientsim/heart-failure.md - GDMT medications
• ../patientsim/chronic-kidney-disease.md - ESAs, phosphate binders
• ../patientsim/behavioral-health.md - Psychiatric medications
• ../patientsim/oncology/ - Oral oncolytics, supportive care

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

Cross-Product: MemberSim (Claims)

Pharmacy and medical benefits are often coordinated:

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 (Demographics & SDOH) - v2.0 Data Integration

PopulationSim v2.0 provides embedded real-world data for realistic medication utilization modeling. When a geography is specified, RxMemberSim uses actual CDC PLACES, SVI, and ADI data to ground prescribing patterns, adherence behaviors, and formulary utilization.

Data-Driven Generation Pattern

Step 1: Look up real population data

# For rural Appalachian county - Pike County, KY (FIPS: 21195)
Read from: skills/populationsim/data/county/places_county_2024.csv
→ DIABETES_CrudePrev: 16.8%
→ BPMED_CrudePrev: 62.1% (on BP medication)
→ ACCESS2_CrudePrev: 9.1% (uninsured)

Read from: skills/populationsim/data/county/svi_county_2022.csv
→ RPL_THEMES (overall SVI): 0.91 (very high vulnerability)
→ EP_POV150: 38.2% (below 150% poverty)
→ EP_NOVEH: 8.4% (no vehicle - affects pharmacy access)

Step 2: Apply rates to pharmacy generation

{
  "cohort_parameters": {
    "geography": { "county_fips": "21195", "name": "Pike County, KY" },
    "expected_drug_classes": {
      "antidiabetics": 0.168,
      "antihypertensives": 0.621
    },
    "adherence_context": {
      "svi_overall": 0.91,
      "transportation_barrier": 0.084,
      "poverty_rate": 0.382
    },
    "data_provenance": {
      "source": "CDC_PLACES_2024",
      "data_year": 2022
    }
  }
}

Step 3: Generate pharmacy claims matching real patterns

• ~17% of members on antidiabetics (not generic 10%)
• High SVI → higher generic utilization (cost sensitivity)
• Transportation barriers → more mail-order, 90-day fills
• Lower adherence rates (MPR ~0.70 vs 0.80 baseline)

Embedded Data Sources for Rx Patterns

Source	File	Use in RxMemberSim
CDC PLACES County	populationsim/data/county/places_county_2024.csv	Medication class utilization (BPMED, etc.)
CDC PLACES Tract	populationsim/data/tract/places_tract_2024.csv	Neighborhood prescribing patterns
SVI County	populationsim/data/county/svi_county_2022.csv	Adherence modeling, generic preference
SVI Tract	populationsim/data/tract/svi_tract_2022.csv	Pharmacy access patterns
ADI Block Group	populationsim/data/block_group/adi_blockgroup_2023.csv	Deprivation → adherence correlation

SDOH Impact on Pharmacy Utilization

SDOH Factor	Pharmacy Impact	Data Source
High SVI (>0.75)	+15% generic utilization, -15% adherence	SVI RPL_THEMES
No vehicle (EP_NOVEH)	+20% mail-order preference	SVI tract data
High poverty (EP_POV150)	Higher copay card utilization	SVI county data
High ADI (>75 percentile)	More early refill rejections	ADI block group

Example: Data-Grounded Diabetic Pharmacy Claims

Request: "Generate pharmacy claims for a diabetic population in Pike County, KY"

Data Lookup:

From places_county_2024.csv (FIPS 21195):
  DIABETES_CrudePrev: 16.8%
  OBESITY_CrudePrev: 41.2%
  BPMED_CrudePrev: 62.1%

From svi_county_2022.csv (FIPS 21195):
  RPL_THEMES: 0.91 (very high vulnerability)
  EP_POV150: 38.2%
  EP_NOVEH: 8.4%

Applied to Generation:

• Drug mix: 70% metformin (generic), 20% sulfonylureas, 10% GLP-1/SGLT2
• Adherence: MPR ~0.68 (below national average due to high SVI)
• Channel: 65% retail, 35% mail-order (transport barriers)
• Copay programs: 25% utilizing manufacturer assistance

Output with Provenance:

{
  "pharmacy_claims": [ ... ],
  "generation_context": {
    "geography": "Pike County, KY (21195)",
    "data_sources": ["CDC_PLACES_2024", "CDC_SVI_2022"],
    "rates_applied": {
      "diabetes_prevalence": 0.168,
      "svi_adherence_modifier": -0.15
    }
  }
}

Key Principle: When geography is specified, ground pharmacy claims in real PopulationSim data. This enables realistic medication adherence modeling, generic utilization patterns, and SDOH-influenced pharmacy access behaviors.

Cross-Product: NetworkSim (Pharmacy Networks)

NetworkSim provides realistic 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 prescription claims in RxMemberSim first, then use NetworkSim to add realistic pharmacy entities with proper NCPDP IDs, network status, 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, GPI, NCPDP codes