Form CMS-304a Prior Quarter Adjustment Statement (PQAS)

PAGE_____Of______
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. __________________________________

PERIOD COVERED: _______________________________________

EMAIL: __________________________________________________

DATE. ________________________________________

A 

B 

PRODUCT/ 
PACKAGE 
CODE 

PRODUCT 
NAME 

TOTALS 

C 

D 

E 

ORIGINAL  CURRENT 
UNIT 
UNIT 
FFS/MCO 
REBATE 
REBATE 
RECORD ID  AMOUNT  AMOUNT 

F 

G 

ORIGINAL  CURRENT  
UNITS 
UNITS 
INVOICED  TO DATE 

H 
PRIOR 
UNITS 
PAID 

I 

J 

CURRENT 
PRIOR 
UNITS PAID 
UNITS 
TO DATE  DISPUTED 

K 

L 

M 

CURRENT 
UNITS 
DISPUTED 
TO DATE 

ORIGINAL 
AMOUNT 
INVOICED 

REVISED 
INVOICE 
 AMOUNT 

N 

O 

P 

Q 

R 

PRIOR 
CURRENT  AMT PAID 
AMOUNT  AMT PAID 
THIS 
ADJM  DISP 
PAID  
TO DATE 
TRANS  CODE  CODE 

CMS-304a (Exp. 06/30/2023)
OMB No. 0938-0676

Plus Interest Payment
===========

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.