Form CMS-304a Prior Quarter Adjustment Statement

MEDICAID DRUG REBATE

PAGE _______ OF ________

PRIOR QUARTER ADJUSTMENT STATEMENT

(for reconciling unit changes, disputed units, and PPAs)

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

PRODUCT

ORIGINAL

CURRENT

ORIGINAL

CURRENT

PRIOR

CURRENT

PRIOR

CURRENT UNITS

ORIGINAL

REVISED

PRIOR

CURRENT

AMT PAID

PACKAGE

PRODUCT

REBATE

REBATE

UNITS

UNITS

UNITS

UNITS PAID

UNITS

DISPUTED

AMOUNT

INVOICE

AMOUNT

AMT PAID

THIS

ADJM

DISP

CODE

NAME

PER UNIT

PER UNIT

INVOICED

TO DATE

PAID

TO DATE

DISPUTED

TO DATE

INVOICED

AMOUNT

PAID

TO DATE

TRANS

CODE

CODE

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

TOTALS

Plus Interest Payment

CMS-304a (Exp.)

Total Remittance

OMB No. 0938-0676

Page F61