A M P

Name Sex (M/F) Date Of Birth Waiting Period End Date Original Effective Date

RACHEL BRENNER F 10/26/2005 05/01/2026 05/01/2025

April 30, 2025

Group: 120800

Subscriber ID: 910793485

RACHEL BRENNER

13118 OLD TULLAHOMA RD

TULLAHOMA, TN 37388

Dear Member:

Welcome to BlueCross BlueShield of Tennessee. We're glad to have you as a new member. We've included some information that will help you understand and start using your new coverage: Benefit Information Summary - This information will help you use your benefits. Bank Draft Authorization Form - You can fill out this form if you'd like to sign up for automatic bank draft.

We're mailing your Member ID card(s) separately, so watch for those in the mail. Your Coverage

Your coverage starts 05/01/2025.

Dental Yes Vision No

Here are the people your plan covers and if you have children, remember they can stay on your plan until they're 26 years old.

Paying Your Premiums

Your total monthly premiums are $27.50.

Dental: $27.50

Vision: $0.00

Your premium is due on the first of each month. We want to make paying your premium as easy as possible. Choose the payment method that's most convenient for you: Online - Make a payment by debit card, automatic bank draft, or e-check using your bcbst.com account. We've included information on how to register below. Automatic bank draft - Sign up in BlueAccess or complete and return the enclosed form with a voided check (in the enclosed envelope).

By phone - Call us at 1-800-***-****, Monday - Friday, 8 a.m. - 6 p.m. ET, for help making a payment by e-check.

By mail - Send a check* for the full premium amount to: BlueCross BlueShield of Tennessee

Individual Billing

P.O. Box 6439

Carol Stream, IL 60197

* Write your Subscriber ID number (it's in the top right corner of this letter) on your check. Get the Most out of Your Plan

Your bcbst.com account lets you view your claims, read details about your coverage, find a doctor, pay your premiums and more. Signing up is easy:

Go to bcbst.com

Click Register.

Enter your BlueCross Subscriber ID number, date of birth, Group number and ZIP code. (Your Subscriber ID and Group numbers are in the top right corner of this letter.) Choose a username and password, then sign in to manage your plan. We're here to help you understand your benefits. If you have any questions, please chat with us at bcbst.com or call us at 1-800-***-****, Monday - Friday, 8 a.m. to 6 p.m. ET. Best of Health,

Your Member Care Team

13189

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