Form CMS-304 Reconciliation of State Invoice

MEDICAID DRUG REBATE

PAGE _______ OF _______

RECONCILIATION OF STATE INVOICE

COMPANY NAME ______________________________________ LABELER CONTACT ________________________________ STATE _____________________________________

LABELER CODE ______________________________________ PHONE __________________________________ INVOICE NO. _______________________________

QUARTER COVERED ____________________________________ FAX ____________________________________ DATE ______________________________________

U N I T S

D O L L A R S

INVOICE

PRODUCT/

ADJUSTED

ADJUSTED

LABELER

REBATE

CORRECTION

WITHHELD

REBATE

PACKAGE

PRODUCT

REBATE

REBATE

UNITS

UNITS

DISPUTED

UNITS

ADJM

DISP

AMOUNT

AMOUNT

INVOICE

AMOUNT

CODE

NAME

PER UNIT

PER UNIT

INVOICED

+ or -

UNITS

PAID

CODE

CODE

INVOICED

+ or -

AMOUNT

PAID

A

B

C

D

E

F

G

H

I

J

K

L

M

N

TOTALS

Plus Interest Payment

CMS-304 (Exp. )

TOTAL REMITTANCE

OMB No. 0938-0676

Page F36