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Gross-to-net optimization analyzer

Models net realized price for a pharmaceutical product by decomposing gross-to-net across every deduction bucket — rebates, chargebacks, co-pay programs, Medicaid best price exposure, fees, and returns — then quantifies…

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Purpose

Decompose a pharmaceutical product's gross-to-net waterfall channel-by-channel, quantify each deduction lever, and surface ranked optimization opportunities — while screening every recommendation against Medicaid best price and 340B ceiling-price exposure so net-improving moves don't trigger downstream statutory penalties.

When to Use

Invoke this skill when the user asks to:

  • Build or analyze a gross-to-net waterfall for a branded product
  • Diagnose why net realized price is eroding vs. list price growth
  • Model the net impact of a proposed rebate, co-pay, or contract change
  • Identify which GTN levers are destroying the most net value
  • Assess Medicaid best-price or 340B exposure from a contracting decision
  • Prioritize GTN optimization opportunities ahead of a pricing or budget cycle

Inputs Required

Before starting, collect:

  • Product & indication: Brand name, therapeutic area, and lifecycle stage (launch / growth / mature / LOE-approaching)
  • WAC (list price): Current wholesale acquisition cost per unit and any recent list price changes
  • Channel/payer mix: % of volume across Commercial, Medicare Part D, Medicaid (FFS + managed), 340B, VA/DoD/FSS, and cash/other
  • Contract structures: Current rebate rates by payer segment, admin fees, chargeback terms, and any value-based or portfolio contracts
  • Patient support programs: Co-pay card design (cap, max benefit, accumulator/maximizer exposure), free drug/PAP volume
  • Current GTN: Reported GTN % or net-to-gross ratio, and the largest deduction buckets if known
  • Objective: Improve net price, defend access, expand volume, or protect best price — with any hard constraints

If channel mix percentages are missing, use category-typical splits for the therapeutic area and flag the assumption. If Medicaid best price status is unknown, model both scenarios.

Instructions

Step 1: Build the Gross-to-Net Waterfall

Construct the full deduction stack from WAC down to net realized price. Express each line as both $/unit and % of WAC:

  1. Gross sales (WAC × volume) — starting point
  2. Prompt-pay / cash discounts — typically 2%
  3. Chargebacks — the gap between WAC and contracted price for 340B, FSS/Big 4, GPO, and other contract-eligible channels
  4. Commercial rebates — formulary rebates, access rebates, market-share/tier rebates
  5. Medicare Part D rebates — plan rebates plus the manufacturer coverage gap discount (mandatory 70% in the gap)
  6. Medicaid rebates — statutory URA (23.1% branded + CPI-U penalty) plus supplemental rebates
  7. Co-pay assistance — card redemptions net of accumulator/maximizer leakage
  8. Fees — distribution service fees, admin fees, GPO fees, data fees
  9. Returns & other — returns reserve, patient assistance write-offs

Sum deductions and report Net Realized Price and GTN % (net ÷ gross).

Step 2: Size and Rank the Levers

For each deduction bucket, quantify total $ impact and % of total GTN erosion. Rank largest to smallest and label each as:

  • Statutory/fixed (Medicaid URA, coverage gap discount) — limited discretion
  • Contractual (commercial/Part D rebates, chargebacks, fees) — negotiable
  • Discretionary (co-pay design, supplemental rebates, VBCs) — full control

Concentrate optimization attention on contractual and discretionary levers; statutory levers are managed, not optimized.

Step 3: Medicaid Best Price & 340B Screen

Before recommending any lever change, run the guardrail check:

  • Best price test: Identify the lowest net price offered to any eligible commercial customer — this sets Medicaid best price and, via the ceiling price formula, drags the 340B price down
  • Trigger risks: Deep single-customer commercial discounts, aggressive supplemental rebates, and certain co-pay/VBC structures can reset best price
  • Exemptions to leverage: Bona fide service fees at fair market value, nominal price sales to eligible entities, and properly structured co-pay assistance may be excluded from best price when designed correctly
  • Flag any proposed move that would lower best price and estimate the Medicaid + 340B spillover cost

Step 4: Channel-Level Net Economics

Compute net realized price for each channel separately (Commercial vs. Part D vs. Medicaid vs. 340B vs. cash). Identify:

  • Which channels are net-accretive vs. net-dilutive
  • Whether volume is shifting toward lower-net channels (mix erosion)
  • 340B penetration trend and its compounding effect on chargebacks

Step 5: Optimization Opportunities (Ranked)

Generate 8–10 opportunities ranked by expected net-price impact, each with: the lever, the mechanism, estimated net $ impact directionally, best-price/340B risk rating, and access trade-off. Draw from:

  • Rebate architecture: Shift flat rebates to market-share tiers; right-size access rebates against realized formulary position
  • Co-pay program redesign: Deploy accumulator/maximizer countermeasures, cap max benefit, tighten eligibility to reduce leakage
  • Contract rationalization: Trim contracts delivering rebate without access; renegotiate fees above FMV
  • Channel mix management: Manage 340B eligibility verification and duplicate-discount prevention; steer to net-accretive channels where compliant
  • Value-based contracting: Structure outcomes-based deals that protect best price via proper accounting treatment
  • Gross price strategy: Assess WAC actions against CPI-penalty and coverage-gap exposure

Step 6: Quantified Scenario & Net Impact Summary

Model a base case vs. optimized case GTN waterfall side by side. Show the net-price delta, the GTN % improvement, and the estimated annual net revenue impact. Include the best-price impact check for the optimized scenario.

Output Format

  • Structure: GTN waterfall table → lever ranking → best-price/340B screen → channel-level economics → ranked opportunities → base vs. optimized scenario
  • Length: 1,000–1,400 words
  • Format: Tables for the waterfall and channel economics; ranked numbered list for opportunities; prose for the best-price screen and summary
  • Sections: Gross-to-Net Waterfall → Lever Sizing & Ranking → Medicaid Best Price & 340B Screen → Channel-Level Net Economics → Ranked Optimization Opportunities → Base vs. Optimized Scenario
  • Tone: Pricing/access director — quantitative, compliance-aware, decision-oriented; flags trade-offs explicitly rather than overpromising net gains

Quality Checklist

Before delivering output, verify:

  • [ ] The waterfall includes all nine deduction buckets and reconciles from gross to a stated Net Realized Price and GTN %
  • [ ] Each line item is expressed in both $/unit and % of WAC
  • [ ] Levers are labeled statutory / contractual / discretionary and ranked by $ impact
  • [ ] Every recommended optimization carries a best-price/340B risk rating — no lever change is proposed without the screen
  • [ ] Channel-level net price is computed separately for at least Commercial, Part D, Medicaid, and 340B
  • [ ] The base vs. optimized scenario shows a quantified net-price delta and annual net revenue impact

Notes

  • The largest single controllable lever in most branded portfolios is commercial rebate architecture, not co-pay — but co-pay leakage from accumulators/maximizers is frequently the most underestimated erosion source
  • Never recommend a net-improving commercial discount without checking whether it becomes the new Medicaid best price — a small commercial gain can create a much larger statutory loss
  • Bona fide service fees and correctly structured VBCs are the two most reliable ways to deliver value without resetting best price
  • When channel mix data is directional rather than exact, present the waterfall as a range and identify the assumption driving the widest sensitivity

How to use this skill

This file is a Claude Code skill in Anthropic's standard format — markdown with YAML frontmatter at the top.

Installing in Claude Code:

  • ~/.claude/skills/<folder-name>/SKILL.md — auto-loads in every session anywhere on your machine (recommended for skills you'll use across multiple projects)
  • <your-project>/.claude/skills/<folder-name>/SKILL.md — auto-loads only when working in that project (recommended for project-specific skills)

Restart Claude Code or open a new session to register.

Using in Claude.ai, ChatGPT, Gemini, or other AI tools:

  1. Drag this file into a new chat, or copy and paste its contents
  2. Send your task or request as your next message — the AI will apply the skill where it fits

For Claude Code skill details: https://docs.anthropic.com/en/docs/claude-code/skills