Crosswalk - Prior Quarter Adjustment Statement (PQAS)

2017 (old version)	2019 (new version)	Type of Change	Reason for Change	Burden Change
Header - PRIOR QUARTER ADJUSTMENT STATEMENT	Header - PRIOR QUARTER ADJUSTMENT STATEMENT (PQAS)	Rev	To align verbiage with other Medicaid Drug Rebate Program documentation.	N/A
Quarter Covered	Period Covered	Rev	To align verbiage with other Medicaid Drug Rebate Program documentation.	N/A
Rebate Per Unit	Unit Rebate Amount	Rev	To align verbiage with other Medicaid Drug Rebate Program documentation.	N/A
Adjusted Rebate Per Unit	Adjusted Unit Rebate Amount	Rev	To align verbiage with other Medicaid Drug Rebate Program documentation.	N/A
According to the Paperwork Reduction Act of 1985, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB 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.	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 OMB 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.	Rev	To conform to new disclosure statement rules	N/A