Track Change - Prior Quarter Adjustment Statement (PQAS)

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MEDICAID DRUG REBATE

PRIOR QUARTER ADJUSTMENT STATEMENT (PQAS)

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

LABELER NAME: ______________________________________ LABLER CONTACT: _______________________________________ STATE: _______________________________________

LABELER CODE: ______________________________________ _ PHONE: __________________________________________________ INVOICE NO. __________________________________

QUARTERPERIOD COVERED: __________________________________ FAX: ____________________________________________________ DATE: _________________________________________

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PRODUCT/ PACKAGE CODE

PRODUCT NAME

FFS/MCO RECORD ID

ORIGINAL UNIT REBATE AMOUNT

CURRENT UNIT REBATE AMOUNT

ORIGINAL UNITS INVOICED

CURRENT UNITS TO DATE

PRIOR UNITS PAID

CURRENT UNITS PAID TO DATE

PRIOR UNITS DISPUTED

CURRENT UNITS DISPUTED TO DATE

ORIGINAL AMOUNT INVOICED

REVISED INVOICE AMOUNT

PRIOR AMOUNT PAID

CURRENT AMT PAID TO DATE

AMT PAID THIS TRANS

ADJM CODE

DISP CODE

TOTALS

CMS-304a (Exp. 06/30/2020) Plus Interest Payment

OMB No. 0938-0676 ===========

TOTAL REMITTANCE

Form CMS-304a (PQAS: Prior Quarter Adjustment Statement) is required for manufacturers only in those instances where a change to an original quarterly rebate data submittal is necessary.  When needed, the use of Form CMS-304a by manufacturers is considered mandatory under the authority of Section 1927 of the Social Security Act and the National Drug Rebate Agreement. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid control number for this information collection is 0938-0676. The time required to complete this information collection is estimated to average 28 hours per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland, 21244-1850.