For: Anthem Sr Advantage or Medicare Preferred in Ohio, Kentucky & Indiana, please call toll free: 1.855.408.8557 or for local calls: 1.813.280.8256
For: Aetna Medicare, please call 1.866.269.3692
I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.
Signature of Patient or Representative