Rxmembersim

---
name: healthsim-rxmembersim
description: "RxMemberSim generates realistic synthetic pharmacy data for testing PBM systems, claims adjudication, and drug utilization review. Use when user requests: (1) pharmacy claims or prescription data, (2) DUR alerts or drug interactions, (3) formulary or tier cohorts, (4) pharmacy prior authorization, (5) NCPDP formatted output."
---

# 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"

```json
{
  "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:

| Cohort | Trigger Phrases | File |
|----------|-----------------|------|
| **Retail Pharmacy** | prescription, fill, refill, copay, retail | [retail-pharmacy.md](retail-pharmacy.md) |
| **Specialty Pharmacy** | specialty drug, biologics, limited distribution | [specialty-pharmacy.md](specialty-pharmacy.md) |
| **DUR Alerts** | drug interaction, DUR, therapeutic dup, early refill | [dur-alerts.md](dur-alerts.md) |
| **Formulary Management** | formulary, tier, coverage, preferred | [formulary-management.md](formulary-management.md) |
| **Rx Enrollment** | rx enrollment, pharmacy member, BIN PCN, rx coverage | [rx-enrollment.md](rx-enrollment.md) |
| **Rx Prior Auth** | rx prior auth, pharmacy PA, step therapy, formulary exception | [rx-prior-auth.md](rx-prior-auth.md) |
| **Rx Accumulators** | rx accumulator, pharmacy deductible, rx OOP, TrOOP, Part D phase | [rx-accumulator.md](rx-accumulator.md) |
| **Manufacturer Programs** | copay card, PAP, patient assistance, copay assistance, hub program | [manufacturer-programs.md](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](../../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](../../formats/ncpdp-d0.md) for transformation.

## Examples

### Example 1: Generic Fill - Paid

**Request:** "Generate a paid pharmacy claim for lisinopril"

```json
{
  "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"

```json
{
  "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"

```json
{
  "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"

```json
{
  "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](retail-pharmacy.md) | Chronic disease meds, discharge Rx | Fill date +0-3 days from order/discharge |
| [specialty-pharmacy.md](specialty-pharmacy.md) | Oncology, biologics | Limited distribution, PA often required |
| [dur-alerts.md](dur-alerts.md) | Multi-drug regimens | DDI based on patient's med list |
| [rx-prior-auth.md](rx-prior-auth.md) | High-cost drugs | Clinical criteria from PatientSim |

**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:

| RxMemberSim Skill | MemberSim Skill | Integration |
|-------------------|-----------------|-------------|
| [formulary-management.md](formulary-management.md) | [plan-benefits.md](../membersim/plan-benefits.md) | Coordinated benefit design |
| [rx-accumulator.md](rx-accumulator.md) | [accumulator-tracking.md](../membersim/accumulator-tracking.md) | Combined deductible/OOP |
| [rx-prior-auth.md](rx-prior-auth.md) | [prior-authorization.md](../membersim/prior-authorization.md) | Pharmacy vs. medical PA |
| [rx-enrollment.md](rx-enrollment.md) | [enrollment-eligibility.md](../membersim/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](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](../networksim/integration/pharmacy-for-rx.md) | Pharmacy with NCPDP, NPI |
| Formulary context | [formulary-for-rx.md](../networksim/integration/formulary-for-rx.md) | Tier, PA requirements |
| Pharmacy benefit | [synthetic-pharmacy-benefit.md](../networksim/synthetic/synthetic-pharmacy-benefit.md) | Benefit design |
| Specialty pharmacy | [specialty-pharmacy.md](../networksim/reference/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](../../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).