2023
APCN+ Health Plan Offerings*
Aetna Premier Care Network Plus – Allina Health Performance Network
40SQ Health Plan Summary 2022 APCN+ 5.2022
Contact Information:
1020 Innovation Lane | Mankato, MN 56001
1-844-205-9579 | [email protected] | www.40Square.coop
* If you reside outside of these counties, you are not eligible to enroll in these plans.
**HSA Compatible Plan
***Embedded means, the Family Deductible and/or the Family Maximum Out-of-Pocket must be satised by two or more covered lives. The Maximum Out-of-Pocket may be satised by any combination of Deductible, Coinsurance
and Copay charges.
This is a benet summary only and does not outline all the benets and exclusions under the plan. Please see the full legal plan document for details.
Your Benets and amount you pay after Deductible (except where noted)
Plan
$1,000
Deductible
$5,500
Deductible**
$8,700
Deductible
Aetna Premier Care Network Plus (APCN+) –
Allina Health Performance Network
The Aetna Premier Care Network Plus (APCN+) – Allina Health Performance
Network is a focused network available to eligible employees who reside in one
of the listed 13 counties. If the employee resides outside one of these counties,
they are not eligible to enroll in the APCN+ plan options.
• Anoka
• Brown
• Carver
• Chisago
• Dakota
• Hennepin
• Isanti
• Nicollet
• Ramsey
• Rice
• Scott
• Washington
• Wright
Strong Access:
• 18,000 +Providers
• 40 Hospitals
• 29 Urgent Care Centers
• 44 Minute Clinic Locations
• Includes the Mayo Clinic Health System
Employees and/or dependents enrolled in an APCN+ plan who are traveling
outside of Minnesota or away at college, will have access to the national Aetna
network at the in-network benet level.
Benet In-Network In-Network In-Network
Annual Deductible***
• Individual
•
Family
$1,000
$2,000
$5,500
$11,000
$8,700
$17,400
Your Benet Coinsurance &
Out-of-Pocket Maximum***
• Individual
•
Family
Deductible and 20%
$4,000
$8,000
Deductible and 25%
$7,050
$14,100
Covered 100% after
Deductible
$8,700
$17,400
Oce Visits (Illness and Injury)
• Primary Care Physican (PCP)
•
Specialist
•
Retail Health Clinic
•
Urgent Care
•
Virtual Visits
$30 Copay
$60 Copay
$20 Copay
$60 Copay
Based on provider
specialty
(Deductible does
not apply)
25%
25%
25%
25%
25%
Covered 100% after
Deductible
(First 3 PCP Visits
Covered at 100%)
Routine Preventive Care
Covered at 100% Covered at 100% Covered at 100%
Hospital & Professional Services
Inpatient, Outpatient, and
Emergency Room
20% 25%
Covered 100% after
Deductible
Prescription Drugs
Retail
• Generic
•
Formulary
•
Non-formulary
Mail-Order
• Generic
•
Formulary
•
Non-formulary
Specialty (per scri
pt)
31-Day Supply
$10 Copay
$60 Copay
$120 Copay
90-Day Supply
$25 Copay
$150 Copay
$300 Copay
30% Coinsurance
*Preventive Drugs are
covered at a Copay
*Non-Preventive Drugs
you pay Deductible,
then 25%
31-Day Supply
$10 Copay
Covered 100% after Ded
Covered 100% after Ded
90-Day Supply
$25 Copay
Covered 100% after Ded
Covered 100% after Ded
Covered 100% after Ded
Benet Out-of-Network
Benet Percentage &
Out-of-Pocket Maximum***
Deductible: Individual $10,000 and Family $20,000
Coinsurance Percentage: 50%
Maximum Out-of-Pocket: Unlimited
+ Represents participating hospitals
Retail Clinics HealthHUBsUrgent Cares AllHospitals
Performance Go Plus Network
Hospitals
Isanti
Kanabec
Aitkin
Wright
Anoka
HennepinHennepin
Washington
DakotaDakota
RiceRice
Le Sueur
Blue EarthBlue Earth
Waseca
Olmsted
Winoa
Wabasha
Fillmore
Mower
Freeborn
Faribault
Goodhue
Martin
Jackson
Watonwan
Nobles
CottonwoodCottonwood
Murray
PipestonePipestone
LincolnLincoln
Lyon Redwood
Renville
KandiyohiKandiyohi
Lacqui ParleLacqui Parle
Chippewa
Swift
Meeker
Stearns
Pope
Stevens
TraverseTraverse
Big StoneBig Stone
GrantGrant
Douglas
Todd
Morrison
Benton
SherburneSherburne
Mille LacsMille Lacs
Pine
ChisagoChisago
Carlton
Saint Louis
Itasca
Koochiching
Beltrami
Roseau
Marshall
KittsonKittson
Pennington
Lake of the
Woods
Hubbard
Becker
Otter Tail
WadenaWadena
Wilkin
ClearwaterClearwater
Polk
Norman
MahnomenMahnomen
Lake
Cook
Yellow MedicineYellow Medicine
Houston
Nicollet
ScottScott
CarverCarverMcLeodMcLeod
Sibley
Brown
Steele
Crow Wing
Ramsey
40 Hospitals
27 urgent
care centers
50 Retail
Clinics
5 HealthHUB
3,500+ primary
care providers
16 ,15 0 +
specialists
For illustrative purposes only.
City Hospital
Aitkin Riverwood Healthcare Center
Albert Lea Mayo Clinic Health System Albert Lea
Arlington Ridegview Sibley Medical Center
Austin Mayo Clinic Health System Austin
Buffalo Buffalo Hospital
Cambridge Cambridge Medical Center
Cannon Falls Mayo Clinic Health System Cannon Falls
Chaska Two Twelve Medical Center
Coon Rapids Mercy Hospital
Crosby Cuyuna Regional Medical Center
Fairmont Mayo Clinic Health System Fairmont
Faribault District One Hospital
Fridley Mercy Hospital-Unity Campus
Glencoe Glencoe Regional Health Services
Hastings Regina Hospital
Hutchinson Hutchinson Health Hospital
La Crescent MCHS Franciscan Medical Center
Lake City Mayo Clinic Health System Lake Cit y
Le Sueur Ridgeview Le Sueur Medical Center
Mankato Mayo Clinic Health System Mankato
Minneapolis Abbott Northwestern Hospital
Minneapolis Children’s Hospital and Clinic
City Hospital
Minneapolis Phillips Eye Institute
Mora Welia Health
New Prague Mayo Clinic Health System New Prague
New Ulm New Ulm Medical Center
Northfield Northfield Hospital
Owatonna Owatonna Hospital
Plymouth Abbott Northwestern WestHealth
Red Wing Mayo Clinic Health System Red Wing
Rochester Mayo Clinic Health System Springfield
Rochester Mayo Clinic Hospital
Rochester-St. Mary’s Campus
Shakopee St. Francis Regional Medical Center
Sleepy Eye Sleepy Eye Medical Center
Springfield Mayo Clinic Health System Springfield
St. James Mayo Clinic Health System St. James
St. Paul Children’s Hospital and Clinic
St. Paul Courage Kenny Rehabilitation
InstituteUnited
St. Paul Gillette Children’s Specialty Healthcare
St. Paul United Hospital
St. Peter River’s Edge Hospital & Clinic
Waconia Ridgeview Medical Center
Waseca Mayo Clinic Health System Waseca
Blue listings are part of the Allina Health system. When searching for a provider or facility,
consider choosing one of these to experience highly coordinated care. All facilities listed
here are part of the Performance Go Plus Network.
Aetna Premier Care Network Plus (APCN+)
Allina Health – Choice POSII
Contact Information:
1020 Innovation Lane | Mankato, MN 56001
1-844-205-9579 | [email protected] | www.40Square.coop
40SQ Health Plan Summary 2022 APCN+ 5.2022
How to Find a Provider
To nd participating Aetna Premier Care Network Plus (APCN+) providers near you, go to: https://bit.ly/APCNPlusProviderSearch
Scroll down to Aetna Premier
Care Network Plus and select:
“Aetna Premier Care Network
Plus (APCN Plus) -Allina Health –
Choice POSII”
Once selected, click continue.
You can search for APCN+ providers by location, specialty, specic
name of doctor, hospital, or clinic. Select the type of provider or
facility you are searching for.
The APCN+ network is only for those that reside in one of the 13 counties
listed below.
• Anoka
• Brown
• Carver
• Chisago
• Dakota
• Hennepin
• Isanti
• Nicollet
• Ramsey
• Rice
• Scott
• Washington
• Wright
To begin your search, without a login, enter the zip code, city, county or state
under the “Continue as Guest” section.
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