| 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"
{
"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":
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"
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":
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
},
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:
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:
Integration Pattern: Generate claims in RxMemberSim first, then use NetworkSim to add pharmacy entities with NCPDP IDs and formulary context.
Output Formats
Reference Data
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.
