Reconciliation of State Invoice (ROSI) (CMS-304) and Prior Quarter Adjustment Statement (PQRS) (CMS-304a)

OMB 0938-0676

Section 1927 of the Social Security Act requires drug manufacturers to enter into and have in effect a rebate agreement with CMS in order for States to receive funding for drugs dispensed to Medicaid recipients. Drug manufacturers must explain to States any rebate payment adjustments for the current quarter, and any prior quarters. The information is used to reconcile drug rebate payments made by manufacturers with the State invoices of rebates due.

The latest form for Reconciliation of State Invoice (ROSI) (CMS-304) and Prior Quarter Adjustment Statement (PQRS) (CMS-304a) expires 2023-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-304a Prior Quarter Adjustment Statement (PQAS) (CMS-304a) Form
CMS-304_304a - Supporting Statement A (2024 version 6).docx Supporting Statement A
Reconciliation of State Invoice (ROSI) (CMS-304) Instruction
Prior Quarter Adjustment Statement (PQAS) (CMS-304a) Form
CMS-304 and CMS-304a – One-Time System Updates

All Historical Document Collections

202403-0938-004	Revision of a currently approved collection	2024-03-07
202102-0938-015 Approved without change	Revision of a currently approved collection	2021-02-26
202003-0938-011 Approved without change	Revision of a currently approved collection	2020-03-31
201704-0938-010 Approved without change	Extension without change of a currently approved collection	2017-04-28
201407-0938-009 Approved without change	Extension without change of a currently approved collection	2014-07-22
201107-0938-007 Approved without change	Revision of a currently approved collection	2011-07-20
201001-0938-009 Approved with change	Extension without change of a currently approved collection	2010-01-27
200612-0938-003 Approved without change	Extension without change of a currently approved collection	2006-12-13
200402-0938-002 Approved with change	Revision of a currently approved collection	2004-02-05
200101-0938-008 Approved without change	Extension without change of a currently approved collection	2001-01-30
199909-0938-010 Approved without change	No material or nonsubstantive change to a currently approved collection	1999-09-30
199712-0938-007 Approved without change	Extension without change of a currently approved collection	1997-12-24
199701-0938-007 Approved without change	No material or nonsubstantive change to a currently approved collection	1997-01-24
199701-0938-006 Approved without change	No material or nonsubstantive change to a currently approved collection	1997-01-17
199603-0938-003 Approved without change	Revision of a currently approved collection	1996-03-19
199503-0938-004 Approved without change	New collection (Request for a new OMB Control Number)	1995-03-10

OMB Details

Reconciliation of State Invoice (ROSI) (CMS-304)

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-304

Reconciliation of State Invoice (ROSI)

Fillable Printable

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.