Cigna Group Q4 2021 Earnings Call Transcript

Quartr
Provided by Quartr
February 2, 2022

Key Takeaways

  • Cigna delivered a 9% increase in 2021 adjusted revenues to $174B and an 11% rise in adjusted EPS to $20.47, returning over $9B to shareholders; 2022 guidance targets ≥$177B in revenues, ≥$22.40 EPS and a 12% dividend increase.
  • The Evernorth health services segment grew Q4 adjusted revenues by 15% and full‐year revenues by 14%, driven by specialty pharmacy and virtual care, with 2022 adjusted earnings forecasted at ~$6.1B (+5%).
  • Cigna Healthcare posted a full‐year 2021 medical care ratio of 84% (Q4 at 87%) amid elevated COVID‐related claims, and expects a 2022 MCR of 82–83.5% while maintaining pricing and affordability actions to address above‐baseline cost pressures.
  • Q4 after‐tax special charges of $119M for organizational efficiency and $70M for integration are expected to generate $200–225M in run‐rate savings by 2023, supporting further SG&A improvements and operational efficiency.
  • Cigna remains focused on long‐term growth by leveraging pharmacological innovation, mental health expansion, alternative care sites and digital tools across its Evernorth and Cigna Healthcare platforms.
AI Generated. May Contain Errors.
Earnings Conference Call
Cigna Group Q4 2021
00:00 / 00:00

There are 15 speakers on the call.

Operator

Ladies and gentlemen, thank you for standing by for Cigna's 4th Quarter 2021 Results Review. At this time, all callers are in a listen only mode. We will conduct a question and answer session later during the conference and review procedures on how to enter queue to ask questions at that time. As a reminder, ladies and gentlemen, this conference, including the question An answer session is being recorded. We'll begin by turning the conference over to Mr.

Operator

Ralph Jacoby. Please go ahead, Mr. Jacoby.

Speaker 1

Great, thanks. Good morning, everyone, and thank you for joining today's call. I'm Ralph Giacobbe, Senior Vice President of Investor Relations. With me on the line this morning are David Cordani, Cigna's Chairman and Chief Executive Officer and Brian Evanko, Cigna's Chief Financial Officer. In our remarks today, David and Brian will cover a number of topics, including Cigna's 4th quarter and full year 2021 financial results as well as our financial outlook for 2022.

Speaker 1

As noted in our earnings release, when describing our financial results, Cigna uses certain financial measures, adjusted income from operations and adjusted revenues, which are not Directly comparable GAAP measures, shareholders' net income and total revenues, respectively, is contained in today's earnings release, which is posted in the Investor Relations section of cigna.com. We use the term labeled adjusted income from operations and adjusted earnings per share on the same basis as our principal measures of financial performance. In our remarks today, We will be making some forward looking statements, including statements regarding our outlook for 2022 and future performance. These statements are subject to risks and uncertainties that could cause actual results to differ materially from our current expectations. A description of these risks and uncertainties is contained in the cautionary note of today's earnings release and in our most recent reports filed with the SEC.

Speaker 1

Before turning the call over to David, I will cover a few items pertaining to our financial results and disclosures. First, as previously Disclosed with our Form 8 ks filing and investor call on January 24, we announced changes in our segment reporting effective for the Q4 of 2021. These changes were made to align with the company's organizational structure as a result of the pending divestiture of Cigna's International Life Accident and Supplemental Benefits Businesses in 7 Asia Pacific Markets. Effective in the 4th quarter, Cigna's results will be reported through the following 3 groups: Evernorth, Cigna Healthcare and Corporate and Other Operations. The international businesses that will be divested pending the close of the transaction will now be reported in other operations, which is included within corporate and other operations in our earnings release and quarterly financial supplement.

Speaker 1

The International Health business to be retained by Cigna We'll join our U. S. Commercial and U. S. Government offerings in a new segment called Cigna Healthcare.

Speaker 1

This segment replaces the prior U. S. Medical segment. 2nd, regarding our results. In the 4th quarter, we recorded an after tax special item charge of $119,000,000 or $0.36 per share related to a strategic plan to further leverage the company's ongoing growth to drive operational efficiency Through enhancements to organizational structure and increased use of automation and shared services.

Speaker 1

We also recorded an after tax special item charge of $70,000,000 or $0.21 per share for integration and transaction related costs. As described in today's earnings release, special items are Additionally, please note that when we make prospective comments Regarding financial performance, including our full year 2022 outlook, we will do so on a basis that includes the potential impact of future share repurchases and anticipated 2022 dividends. Also, our full year 2022 outlook assumes that the pending divestiture of Cigna's international life accident and supplemental benefits businesses will close in the Q2 of 2022, but does not assume any impact from other business combinations or divestitures that may occur after today. Finally, I would like to announce our intention to host an Investor Day in June, where we will discuss our long term strategic growth and value creation story. We look forward to sharing more details in the coming weeks.

Speaker 1

With that, I will turn the call over to David.

Speaker 2

Thanks, Ralph. Good morning, everyone, and thank you for joining our call today. As we step into 2022, our clients, customers and patients continue to face a rapidly changing landscape With new COVID variants, changing testing and treatment protocols and pressures on the global economy. Throughout these challenges, we've remained focused on addressing and balancing the evolving needs of all of our stakeholders. As a result, our 70,000 plus colleagues around the world Continue to deliver differentiated value for those we serve and also continue to grow our businesses.

Speaker 2

Today, I'll share perspective around our 20 21 performance and the sustained growth opportunities we see for our organization in the year ahead. And Brian will provide additional details about our 2021 financial results and our 2022 outlook. Then we'll take your questions. With that, let's get started. In 2021, We grew full year adjusted revenues to $174,000,000,000 a second consecutive year of growth above our long term target.

Speaker 2

We delivered full year adjusted earnings per share growth of 11% to $20.47 and we returned over $9,000,000,000 to shareholders in dividends Additionally, we continue to invest in our capabilities to ensure we are positioned for sustained growth in 2022 and beyond. Our growth is and will continue to be fueled by our 2 high performing platforms. Evernorth, our health services business, including pharmacy, care, Benefits and Intelligence Services and Cigna Healthcare, which includes our portfolio of U. S. Commercial, U.

Speaker 2

S. Government and international health businesses. Our Evernorth and Cigna Healthcare platforms complement each other through the breadth of their capabilities and the ability to serve multiple buyer groups. Here we typically lead with either a medical or pharmacy solution and then we build on those relationships by innovating and delivering new services. We have a proven track record with this approach, a diverse high performing portfolio of solutions and a sustained commitment to continued innovation We see this as extremely valuable in a dynamic environment.

Speaker 2

Relative to our 2021 performance, It was a very strong year for Evernorth. We grew adjusted revenues by 14% in 2021 as Evernorth's corporate clients, health plans, Government latencies and healthcare delivery system partners increasingly recognize the value of our health services, including in our specialty pharmacy business, which I'll discuss in more In our virtual health capabilities, which have been expanded through MD Live to include urgent and dermatology care as well as behavioral health services In our core pharmacy services portfolio, which continues to generate outstanding results for our clients, And we are further broadening our reach through deeper and new partnerships. For Cigna Healthcare, we had sustained growth, leveraging the strength of our U. S. Commercial, U.

Speaker 2

S. Government and International Health Businesses. As we previously discussed, we also experienced elevated medical costs. We had higher claims costs in our commercial insured and stop loss businesses and continued higher claims from our special enrollment period customers within the These included the impact of elevated COVID costs for testing treatment of vaccines. The elevated Trend continued throughout the year.

Speaker 2

As a result, our medical care ratio for Cigna Healthcare was 84% for full year 2021. As Brian will discuss in further detail, we took targeted pricing and affordability actions earlier in 2021 for 2022 impact as we continue to prioritize margin expansion for 2022. As I highlighted earlier, the breadth complementary nature of our portfolio enabled us to exceed our revenue and EPS outlook and return over $9,000,000,000 of capital to our shareholders. Looking forward to 2022, we expect to continue to capitalize on emerging growth opportunities and achieve sustained attractive performance. We see additional opportunities to drive growth by leveraging Evernorth's capabilities to respond to 3 forces that we believe are fundamentally reshaping the future of healthcare.

Speaker 2

They are pharmacological innovation, the increased recognition of the link between mental and physical health and third, the growing trend toward alternative sites of care. I'll start by highlighting how Evernorth will lead the way to capitalize on the first trend, pharmacological innovation. New drugs represent 1 Most promising areas for medical innovation in the coming years and we're seeing a dramatic growth in specialty pharmaceuticals, gene therapies and vaccines. These potentially life saving and life changing advances also bring intensifying pressures on affordability. This creates significant opportunity for EverNorth to provide customers, patients and clients with the most innovative new therapies In ways that are accessible, affordable and predictable.

Speaker 2

By 2025, for example, 66 biologic drugs Currently in the market, we'll have the patents expire, opening the door for increased biosimilar competition and an increasing opportunity We need to decrease healthcare spending by an estimated $100,000,000,000 Importantly, this trend is already unfolding in 2022 and will accelerate further in 2023. We are positioned to lead and fully intend to capture a large portion of those savings for the benefit of our customers, patients and clients By combining and coordinating capabilities that include our accreto capability, which provides differentiated specialty pharmacy care for a number of specific conditions, I'd also highlight that today specialty pharmacy already drives fully 1 third of Evernorth's revenue and Accredo is one of the fastest growing parts of our health service portfolio. Additionally, leveraging Express Scripts, which draws upon its expertise in delivering improved affordability, leveraging a broad network, supply chain expertise, as well as clinical and service capabilities. Managing biologics and specialty drugs is also a priority focus for our Cigna Healthcare Last year, we launched an innovative program to leverage biosimilars in the medical benefit that included incentives that improve access for integrated clients and customers. This illustrates just one way we will continue to leverage Evernorth's capabilities to drive greater affordability and value for our Cigna Healthcare clients and customers.

Speaker 2

Evernorth will also continue to grow from the significant demand for more mental health services as well as the rapidly changing access to care models. For example, Evernorth is continuing to expand our virtual care services by leveraging our MD Live platform as well as expanding our behavioral care network. We know how important this is for both patients as well as clients. Our Evanurath research reinforces that total healthcare costs decrease When people who are diagnosed with behavioral conditions receive coordinated sustained treatment. For Cigna Healthcare in 2022, we expect to drive customer growth in each of our U.

Speaker 2

S. Commercial market segments and grow earnings as we continue executing on our affordability and pricing actions throughout 2022. Additionally, Cigna Healthcare will continue to partner and leverage our EverNorth innovations. For example, we're continuing to expand digital experiences that help our customers connect with the highest performing and most affordable medical care. Our recent approach we developed for patients diagnosed with orthopedic and musculoskeletal conditions provide highly personalized and actionable information to guide their choices and support improved healthcare outcomes and affordability.

Speaker 2

In our U. S. Government business, as we've noted previously, we're operating in a more competitive environment stepping into 2022. For Cigna, Aided by the strength of our broad portfolio, we've prioritized pricing discipline for U. S.

Speaker 2

Government business for 2022. For Medicare Advantage, we will start the year with flat membership. Looking forward to 2023, we are confident in our position to accelerate growth further As our customer satisfaction metrics are high, our stars ratings are very strong, and we've steadily expanded our addressable market by entering new geographies. In our individual and family plan business, as noted previously, 2021 customers grew meaningfully in part due to the extended special enrollment period. We expect a decline in customers in 2022, in part driven by our product and price positioning that will adjust The special enrollment surge we saw in 2021, we do continue to view this as an attractive long term opportunity and to support that growth, We continue to enter new markets.

Speaker 2

For 2022, we entered 3 new states and 93 new counties. With these markets, for example, we have the ability to reach Developing our services for the globally mobile as well as go deeper into domestic health and health services. One of the key ways we will do this is with innovative partnerships such as Honeysuckle Health, an analytics driven health service company established in our joint venture with the NIP Group in Australia. Now taken as a whole, 2022 will be another year of attractive growth for our company. Our EPS outlook of at least $22.40 And the increase of our quarterly dividend by 12% reinforces the sustained growth and strength of our businesses.

Speaker 2

Now before I wrap up, I want to reinforce a key aspect of our sustained performance is our positioning strategically To further expand our reach in addressable markets over time, here we will leverage organic, partnerships and targeted inorganic opportunities To further strengthen our proven growth platforms, we see 3 areas of continued focus here. 1st, in US government, We will seek additional growth opportunities and our ability to win in these markets is further enhanced by our current and expanding Evernorth service capabilities. 2nd, we will further expand our Evernorth service portfolio. This includes, for example, our Evernorth care capabilities, including virtual, home and behavioral services. And third, in international health, Our decision to divest our life accident and supplemental benefits business in 7 markets reinforces our discipline to focus on the health portion of our portfolio.

Speaker 2

Now to wrap up, looking back on 2021, our business performed in a dynamic environment. We delivered adjusted EPS of 20 point $4.7 and returned over $9,000,000,000 of capital to our shareholders in dividends and share repurchase. 2022 will be another year of growth across our And we will continue to invest in innovation to position us for sustained long term growth. With that, I'll turn the call over to Brian.

Speaker 3

Thanks, David, and Good morning, everyone. Today, I'll review key aspects of Cigna's Q4 2021 results, and I'll provide our outlook for 2022. Key Key consolidated financial highlights for full year 2021 include adjusted revenue growth of 9% to $174,000,000,000 or growth of 12% When adjusting for the sale of the Group Disability and Life Business. Adjusted earnings of $7,000,000,000 after tax And adjusted earnings per share growth of 11% to $20.47 We delivered these results despite an elevated medical ratio in the quarter. Parprice revenue and EPS results were slightly better than our expectations, reflecting the resilience and breadth of our portfolio With particularly strong performance in Evernorth.

Speaker 3

Regarding our segments, I'll first comment on Evernorth. 4th quarter 2021 adjusted revenues grew 15% to $35,100,000,000 while adjusted pre tax earnings Grew to $1,600,000,000 EverNorth's strong results in the quarter were driven by organic growth, including strong volumes in specialty pharmacy And retail, along with ongoing efforts to improve affordability and deepening of existing relationships. In the quarter, we also continued to increase the level of strategic investments to support ongoing growth of the Evernorth portfolio, such as our Accredo Specialty Pharmacy, our Virtual Care platform and our technology, including digital capabilities. Overall, Evernorth delivered a strong year, focusing on driving value for clients and customers, while achieving strong revenue and earnings growth above It's long term growth targets. Turning to Cigna Healthcare, which as a reminder now includes the prior U.

Speaker 3

S. Medical segment Plus our retained International Health business. Overall, 4th quarter adjusted revenues were $11,200,000,000 Adjusted pretax earnings were $472,000,000 and the medical care ratio was 87%. During the Q4, we experienced elevated medical costs driven in large part by dynamics related to COVID, including higher testing, treatment and vaccine costs. Specifically, the higher than expected 4th quarter costs are attributable to 3 primary areas: Higher stop loss claims, particularly in policies with lower attachment points that were triggered by the cumulative impact COVID and non COVID costs throughout the year.

Speaker 3

Continued pressure on our individual business, particularly the special enrollment period customers who were added in mid-twenty 21 and higher claim costs in our commercial insured book. The elevated medical costs were partly offset By better than expected net investment income and fee based specialty contributions, neither of which are reflected in the medical care ratio metric. For full year 2021, we finished with a medical care ratio of 84%. The unfavorable 4th quarter medical costs Informed and sharpened our 2022 assumptions. We now expect full year 2022 medical costs To run above the corresponding 2022 baseline at a relative level that is consistent with full year 2021.

Speaker 3

This 2022 medical cost outlook is now higher than our previous expectations. And specific to stop loss, We assume the pressure experienced in the Q4 will persist in 2022, and we will take appropriate future action as this book of business renews throughout the year. Helping to offset these pressures as we step into 2022, Our targeted pricing actions we've taken in our U. S. Commercial business as we saw claim costs emerge in 2021, Higher U.

Speaker 3

S. Commercial enrollment and retention than previously expected in our fee based business and incremental affordability Which I'll elaborate on in just a few moments. Turning to membership, we ended the year with 17,100,000 total medical customers,

Speaker 4

an increase of approximately 430,000 customers for

Speaker 3

the full year. 2 430,000 customers for the full year. 2021 customer growth was driven by middle markets and select within U. S. Commercial, Individual and Medicare Advantage within U.

Speaker 3

S. Government and International Health. Overall, Cigna Healthcare supported and delivered for our customers, clients and partners during a challenging year and is well positioned to both grow membership and expand margins in 2022. Turning to corporate and other operations. The 4th quarter adjusted loss was $115,000,000 and now includes positive earnings contributions from our international life, Accident and Supplemental Benefits Businesses held for sale pending divestiture.

Speaker 3

As Ralph noted, during the Q4, We reported a special item charge of $119,000,000 after tax related to actions to improve our organizational efficiency. These actions will capitalize on our scale and the progress we have made through automation, increased use of digital tools and continued innovation to better enable us to grow and expand in this dynamic marketplace. Overall, Cigna's 2021 results reflect our balanced portfolio and our commitment to accretive capital deployment to augment our organic growth. As we turn to 2022, our affordability initiatives, pricing actions and focus on operating efficiencies will drive income growth And margin expansion in Cigna Healthcare. This performance, coupled with continued growth in Evernorth and accretive capital deployment, will drive attractive EPS For the full year 2022 outlook, I'd like to first remind you that our outlook assumes the divestiture of our international life, Accident and Supplemental Benefits businesses will close in the Q2 of this year.

Speaker 3

In total for the company, we expect Consolidated adjusted revenues of at least $177,000,000,000 representing growth of approximately 4%, Excluding the impact from previously announced divestitures, we expect full year consolidated adjusted income from operations to be at least $6,950,000,000 or at least $22.40 per share, consistent with our prior EPS commentary. We project an expense ratio in the range of 6.9% to 7.3%, further improving upon our operational efficiency and ensuring continued affordable solutions for our clients and customers. And we expect a consolidated adjusted tax rate in the range of 22% to 22.5%. I'll now discuss our 2022 outlook for our segments. For EverNorth, we expect full year 2022 adjusted earnings of approximately $6,100,000,000 This represents growth of about 5% over 2021, within our targeted long term income growth range, reflecting strong growth in Accredo Specialty Pharmacy, all while we continue to increase investments in order to drive new innovative solutions to the market.

Speaker 3

For Cigna Healthcare, we expect full year 2022 adjusted earnings of approximately $3,900,000,000 This outlook reflects the strength of our value proposition and focused execution in our business, driven by organic customer growth And disciplined pricing in order to expand margin. Some key assumptions reflected in our Cigna Healthcare earnings outlook for 2022 include the following. Regarding total medical customers, we expect 2022 growth of at least 575,000 customers, With the vast majority coming from an increase in U. S. Commercial fee based customers.

Speaker 3

Within our U. S. Commercial book, organic customer growth is driven by national, middle market and select market segments. We expect Medicare Advantage customers to be relatively flat compared to 2021, reflecting the competitive backdrop. And as David shared, we expect a decrease in our individual customers.

Speaker 3

We expect the 20 2 medical care ratio to be in the range of 82% to 83.5%. As I noted earlier, this outlook assumes total medical cost will be above baseline in 2022. Importantly, we are actively managing overall medical costs with a range of affordability actions, including identifying opportunities such as guiding customers to more effective and efficient sites of care. For example, We focused our eviCore subsidiary on incorporating site of care review to our existing processes. These improvements encourage the use of non hospital settings, which can substantially reduce costs for customers while increasing patient satisfaction.

Speaker 3

This action has contributed to results within our commercial book of business, Where we are now seeing fewer than 20% of all knee and hip replacements occur in an inpatient hospital setting, down from over 75% in 2019. We are also continuing to promote preventive care, The targeted use of virtual care through our MD Live subsidiary and access to behavioral services to provide meaningful support to patients and moderate overall medical costs over the longer term. Through these affordability initiatives and our disciplined pricing actions, We expect to expand margins in 2022 while growing our medical customer base. Now moving to our capital management position and outlook. We expect our businesses to continue to drive strong cash flows And returns on capital, even as we increase strategic reinvestment to support long term growth and innovation.

Speaker 3

In 2021, we finished the year with 7 point $2,000,000,000 of cash flow from operations. Additionally, we returned over $9,000,000,000 to shareholders via dividends and Share repurchase in 2021, a significant increase from 2020. And now framing our capital outlook for 2022. We expect at least $8,250,000,000 of cash flow from operations, up more than $1,000,000,000 from 2021, reflecting the strong capital efficiency of our well performing business. This positions us well to continue creating value through accretive capital deployment in line with our strategy and priorities.

Speaker 3

We expect to deploy approximately $1,250,000,000 to capital expenditures, an increase From our 2021 CapEx levels, the investments will be heavily focused on technology to drive future growth. We expect to deploy approximately $1,400,000,000 to shareholder dividends, reflecting our meaningful quarterly dividend of $1.12 per share, a 12 And we expect to use the proceeds from the divestiture of our international life accident and supplemental benefits businesses, primarily for share repurchase. Our guidance assumes full year 2022 weighted average shares to be in the range of 308,000,000 to 312,000,000 shares. Year to date as of February 2, 2022, we have repurchased 2,500,000 shares for $581,000,000 Our balance sheet and cash flow outlook remains strong, benefiting from our highly efficient service based orientation that drives strategic flexibility, strong margins and attractive returns on capital. So now to recap, our full year 2021 consolidated results reflect strong contributions from our focused growth platforms led by Evernorth.

Speaker 3

Our 2022 outlook reflects meaningful contributions from each of our 2 largest segments, Evernorth and Cigna Healthcare, along with accretive capital deployment. We are confident in our ability to deliver our 2022 full year adjusted earnings of at least $22.40 per share, consistent with our prior EPS commentary. Finally, as Ralph noted, we are looking forward to speaking with you in more detail at our upcoming Investor Day in June. And with that, we'll turn it over to the operator for the Q and A portion of the call.

Operator

Finally, we ask that you please limit yourself to one question to allow sufficient time for questions from those remaining in the queue. One moment please for our first question. Our first question comes from Mr. Scott Fidel with Stephens. You may ask your question.

Speaker 5

Hi, thanks and good morning. I wanted to just ask your thinking about seasonality for both MLR and Adjusted EPS in 2022 relative to 2021 and maybe sort of typical historical seasonality and Just in particular, thinking about the fact that Omicron obviously still having an impact here in the Q1 likely on the commercial Book of business. Then also, as you talked about, given that you're planning to reprice some of the stop loss business throughout the course of the year, Interested in how you're thinking about the sequencing of the MLR over the course of the year as a result of that? Thanks.

Speaker 3

Good morning, Scott. It's Brian. So I'll start with the seasonality component as it relates to the EPS cadence as well as the MCR. For purposes of what we expect relative to quarterly EPS, the 2021 pattern It's actually a reasonable starting point as we think about the 2022 quarterly EPS that will emerge for us. And so More specifically, we would expect a little bit less than half to transpire in the first half of the year.

Speaker 3

And based on what we're Seeing so far in January, the impact of Omicron, etcetera, working its way through our book, there's actually quite a bit of resemblance In terms of January 2022 to 2021, which again reinforces that 2021 is a reasonable framework to use in terms of what to expect relative To EPS seasonality, as it relates to MCR, the full year guidance is, as I indicated, is between 82% And 83.5% for the Cigna Healthcare book of business. So the midpoint of that, you can view As a reasonable starting point for the Q1, we would expect to run a little bit below that in the quarter, just based on, again, what the early read is here in January, With the pattern we saw last year. So again, think of a little bit less than 50% of the overall EPS in the Half of the year. Think of the Q1 MCR being a bit below the midpoint of our full year guide for Cigna Healthcare. As it relates The stop loss book of business within the quarter and importantly, you need to think of this as a Full year accumulation product.

Speaker 3

So what ends up transpiring with this business is over the course of the year, claims are accumulated and then the Q4 Of the policy period, there's essentially a true up. And what we had occur in the Q4 this year is particularly at the smaller end of our stop loss book. We had some of the lower attachment points pierced slightly more heavily than we had been anticipating. And so that created Round numbers, you can think of it as about $70,000,000 of medical cost pressure in the 4th quarter. Importantly, though, that's an Annual number because it reflects the accumulation over the course of the year in 2021.

Speaker 3

So that $70,000,000 that hit in the 4th quarter is really a full year 2021 number. We have assumed that that $70,000,000 of pressure will recur in 2022. So we have not assumed that we'll be able to And that's embedded in our $3,900,000,000 income guide for Cigna Healthcare. So to the extent we're able to reprice Some of the cases with later effective dates in 'twenty two that could provide some level of upside relative to the $70,000,000 assumption that's embedded in the guide.

Operator

Thank you, Mr. Fidell. Our next question comes from Mr. Steven Valiquette with Barclays. You may ask your question.

Speaker 6

Thanks. Good morning, everybody. I apologize if I missed the details around this, but just regarding your commercial membership outlook for 2022, can Can you remind us of your assumptions related specifically to potential additional members from the industry shift of Medicaid members to commercial around re

Speaker 3

Hey, good morning, Steve. It's Brian. I'll start and then David can add So as I mentioned, we're expecting net customer growth in Cigna Healthcare of at least 575,000 customers In 2022, which we're really pleased with and it's actually above what we would have expected a few months ago based on stronger than expected enrollment and retention. As I noted, the vast majority of that will come through in the form of fee based ASO related customer relationships. Our Membership outlook for 'twenty two does not anticipate any growth from Medicaid redeterminations in either the commercial book or the individual book.

Speaker 3

So as you know, we don't continue to participate in the health plan space today in Medicaid. And therefore, as we think of the impact of redetermination, it's only upside Relative to our customer outlook, we have not modeled anything in terms of benefit in there. Anything you want to voice over, David? All I would add, I

Speaker 2

would say is, as I noted in my prepared remarks, within the commercial segment, we're Our full year outlook for 2022 has growth in each of our 3 employer sub segments. So we're pleased with the outlook As we start the year, we're pleased with the outlook for the full year.

Speaker 6

Okay, great. Thanks.

Operator

Thank you, Mr. Vahlicat. Our next

Speaker 7

You're obviously continuing to prioritize expanding in the government side. Two aspects to my question. 1, Is that still primarily on the Medicare side? Or is there any change in the thought about Medicaid opportunities? I know you've always said the More acute end of Medicaid was of interest, but just an update on that.

Speaker 7

And then there's been a lot of discussion about, from an organic standpoint, What's happening in the distribution channels for MA? Maybe get your assessment of where the market is today? And Is your organic growth strategy taking advantage of maybe distribution channels in a different way than what you've done historically?

Speaker 2

Hey, Jay, good morning. It's David. Specific to the government expansion, stepping back first, We continue to see the government space as an interesting and attractive growth space for us. We define that as MA, Individual exchange, we view as part of the government programs as well as Medicaid when we look at the space more broadly. To date, we focus In terms of using our levers and our focus more heavily on MA and on the individual business, and we're pleased to highlight the fact that within our Evernorth service portfolio, Our revenue with service portfolio continues to be able to expand its Medicaid proposition through servicing health plans and other intermediaries.

Speaker 2

Additionally, as I noted in my prepared remarks, as we expand our Evernote service capabilities, we see that as a meaningful value creator To MA, to the individual marketplace as well as to the Medicaid marketplace and we think all of which are going to continue to evolve and be attractive. Specific to the MA distribution channels, no doubt some headlines have been produced relative to a little different dynamic in our posture coming into 2022 was that 2022 was going to be a bit more dynamic year from an MA standpoint. Hence, we manage our portfolio to reduce our internal expectations of life growth and focus heavily on margin Expansion with an eye toward 20 20 2 20 20 three's growth being a more accelerated growth environment. And I think we'll see a little bit more shakeout relative to some Channels that are evolving. For us, our channel traction on our retention has been pretty darn reasonable For 2022, we saw less new business growth year over year for Medicare Advantage, and we expected to see less new business growth in Medicare Advantage given our product

Operator

Our next Question comes from Mr. Gary Taylor with Cowen. Your line is open. You may ask your question.

Speaker 3

Hi, good morning. One question and one Clarification. The question is or maybe they're both clarifications. I just want to go back to the commercial membership growth. I thought Brian had said mostly fee based ASO and then David you had said growth across the segments.

Speaker 3

So I was just trying to Piece together what your outlook was for Select where you've had really the strongest growth and I would think would lean more towards

Speaker 2

Gary, it's David. Your starting part of So when we think about it, we think about national, regional or mid and select. Each of the segments have attractive growth for 20 And 2022 with national and regional having very attractive growth outlook and all being think about that as all fee based. 2nd, to your point, within the Select segment, the Select segment has been and continues to be a very attractive growth segment for us. In any given year, The amount of new business we've written in that segment has varied anywhere between 70% ASO stop loss and 30% risk To greater than 50% risk and less than 50% ASO stop loss, it varies.

Speaker 2

So we'll continue to write, ASO stop loss within the Select segment and we'll write Some guarantee cost business in there, no doubt, but the aggregation of all the segments together and the strength of all three segments going to 20 And 2022 has a significant portion of our net customer growth being in the fee based environment.

Speaker 3

Okay. That makes sense. I'll ask some other clarification offline. Thank you.

Speaker 2

Sure. Thanks.

Operator

Thank you, Mr. Taylor. Our next question comes from Ms. Lisa Gill with JPMorgan. You may ask your question.

Speaker 8

Thanks very much. Good morning. David, can you give us some update around the PBM on the Evernorth side as we think about 20222023? So first off, On 2022, did you see any material changes as we think about contracting or programs that you're offering? And then as we think about The selling season for 2023, I know we're pretty early on, but any insights that you can give us as far as Renewals, book of business that's up for renewal or how we think about how your PBM is doing?

Speaker 2

Sure. Good morning, Lisa. So let me start with The 2023 selling season and to put a backdrop of it, we're pleased with the performance we've carried now over multiple years Within that sub segment of Evernorth in 2023 is guiding toward another attractive year for us. As it relates to when you think about the growth equation you're asking about, we start with retention. We would expect at this point our retention levels for 2023 to be at or above our In 'twenty two retention levels, so we would see that as an attractive outlook.

Speaker 2

For 2023 growth, we have an Pipeline, and so we would see net new business adds coming through. And then context for you And our listeners, if you think about that business portfolio over the last several years, we've essentially had a net add of about 20 health plans into our portfolio of services. So positive and continued, I would say, sustained attractive performance. Importantly, in the earlier part of Comments in terms of you said contracts and programs. I think I draw your attention back to the programs.

Speaker 2

A cornerstone part Of that business is to continue to innovate programs and services. Said otherwise, it's not just a base PBM, or access offering. There's an evolution of programs that you would know as safeguard programs and evolution of safeguard programs that continue to enhance Clinical programs and clinical engagement and clinical care coordination leveraging both what Express Scripts has the ability to do, what Accredo has the ability to do And increasingly what we're able to leverage off of some of the Cigna Healthcare capabilities working in both directions off the medical side of the proposition. So Expansion of the services using your term programs has been mission critical. And the final note I would say is, our PBM team, as you call it, Does a really good job of working client by client, be it a corporate client or in the case of health plans to co collaborate the innovations that work for them.

Speaker 2

And by doing so, helping them, our clients drive growth, which is mutually beneficial to both organizations. So wrapping up, we see 20 20 3 is being another positive year, both from a retention as well as a new business growth standpoint.

Operator

Great. Thank you. Thank you, Ms. Gill. Our next question comes from Mr.

Operator

Justin Lake with Wolfe Research. You may ask your question.

Speaker 9

Thanks. Good morning. I wanted to ask, so you gave us a $70,000,000 number and it sounds like you're going to reprice fully for that in the stop loss book. I know in the rest of the Your commercial risk book, you had some issues in 2021. You were repricing some of them in 2022, but not fully.

Speaker 9

Is there a number that you could share with us that you hope to get back In 2022, for 2023, in terms of repricing there, so we could think about maybe some of the earnings momentum that we could see ahead as you get those books repriced?

Speaker 3

Good morning, Justin. It's Brian. So I think your question was really specific to the fully insured part Commercial book of business. And as I noted in my comments there in the Q4, we saw some elevated medical costs. In all in, you can think of that as also in that same general zone as the stop loss pressure I mentioned of about $70,000,000 So the three drivers of the pressure, The stop loss, the individual exchange and the fully insured, you can think of them as about a third, a third, a third in terms of the medical care ratio pressure we had relative to our expectations in the quarter.

Speaker 3

So the fully insured component of that, going forward, as David indicated in his comments, we started to see pressure emerge in the Q2 of 2021. If you recall, our 2nd quarter MCR was elevated relative to our expectations and that began a cycle of margin expansion on this book of business. We've been repricing over the course of 2021 into 2022 with the expectation of expanding margins. As we've talked about before, we don't expect that all to transpire in 1 year. So when you look at the Cigna Healthcare income guide for next year of this year or this year actually $3,900,000,000 that's up about $300,000,000 from Where we ended in 2021, that will improve our margin profile, but it doesn't get us all the way to our target margins In 1 year.

Speaker 3

So we have more opportunity in 2023 and thereafter for further repricing actions. So in the fully insured book of business in particular, The sold business so far has revenue yields in excess of cost trends. And you can think of that in the range of 100 basis points to 150 basis points as we step into So we'll get some margin expansion in that portfolio. We'd expect more in 'twenty three as more of the business is repriced.

Speaker 5

Thanks.

Operator

Thank you, Mr. Lake. Our next question comes from Mr. Matthew Borsch with BMO Capital Markets. You may ask your question.

Speaker 5

Yes. I was hoping you could just comment a little bit more on the competitive pressures, excuse me, in Medicare Advantage. And At what point did you come to realize that those were going to meaningfully impact your enrollment outlook? And just sorry, just related to that, I was partly really that if you can maybe give one comment on Do you advance notice on the 2023 rates we got last night?

Speaker 2

Hey, Matt, it's David. So specific to the Medicare Advantage environment for 2022, we were mindful of our willingness to trade, if you will, volume for margin As we're establishing our pricing for 2022, earlier in 2021, did we have perfect insight? Of course not, But we are mindful of that. To answer your question more specifically, clearly when the competitive Pricing by market became visible as you get ready to step into the annual enrollment period. We're able to look at market by market and we're able to broadly see, I mean, most markets, Our level of benefit and price point positioning clicking down 1 to 3 notches by market.

Speaker 2

So that gives you a context. And that's in an environment with a local scale with attractive medical cost configuration and with The SARs rating deep into the 80s. So as we looked at that environment, again, we were mindful of what was transpiring. And at that point, we were able to see that there would be more volatility. As I noted before, we saw reasonable retention, a little bit of pressure on retention, but less new business sales that came through.

Speaker 2

Now specific to your point, it's early. Folks are combing through what was posted last night. But big picture, I put the headline number aside. It looks like a little over 4% Net yields for the industry, and our assessment of ourselves when you look at mix, kind of shaking it through is about 4% yield With an eye toward 2023, we view that as a positive, taking our current proposition, taking our current STARS rating, Taking our current Net Promoter Score, taking the geographies we've expanded in, and our disciplined orientation of stabilizing environment for 2022. So we're looking forward to a very attractive growth opportunity for the Medicare Advantage portfolio business in 2023.

Speaker 5

Thank you.

Operator

Thank you, Mr. Bork. Our next question comes from Mr. Josh Raskin with Nephron Research. You may ask your question.

Speaker 10

Hi, thanks and good morning. I'll congratulate Ralph for joining. I want to get back to the comments that you made about the inorganic growth Specifically in the government segment and I think and perhaps this is the answer understanding that there are significant potential synergies with Evernorth for New blocks of business in the government segment, but maybe just help us what's changed over the last couple of years? What is most attractive For potential targets in your mind, how important is scale, large scale? And do you consider the organization prepared for large scale M and A at this point.

Speaker 10

And then lastly, the last big one I think about in the government segment was HealthSpring. That asset, that growth rate hasn't really kept up with the market. So I'm curious if there are lessons learned or things that you think are different this time around in terms of Yes, Cigna operating at larger scale in the government segment.

Speaker 2

Jeff, good morning. When you think about our inorganic priorities, first, Our inorganic priorities augment our organic growth and then our disciplined focus to We have 4 categories, and I'll come to your core point in a second. Four categories of focus, Furthering our international proposition in key markets on the health space, furthering our U. S. Government capabilities, furthering our care delivery and management capabilities We're oriented toward the digital, the home, the behavioral side of the equation and then digital and technology support for our organization.

Speaker 2

As it relates to inorganic opportunities in the government space, I'm not going to call out any one as a priority. There's multiple sub segments. But as we look at inorganic priorities, To your point of scale, we have to conclude that, of course, they're strategically attractive, then we have to conclude they're financially attractive, and then we have to conclude that we could Essentially close them or create a level of certainty. So within the context of that, we take into consideration all the items in your question. Regulatorally, we recognize the environment is quite fluid From a financial attractiveness, this includes the organizational readiness and our ability to create and capture value.

Speaker 2

We have to conclude for a larger transaction That the transaction will be accretive in its 1st full year of operations and generate an attractive ROI take. So that's an important part of the equation for us in terms of the way in which we would approach our transactions from that standpoint. And on a final note, we've built a diverse Portfolio, within Cigna, demonstrating that our services portfolio is well positioned for continued growth. And then within our Cigna Healthcare portfolio, we have multiple growth levers from commercial to government to our international health capability. So we'll be opportunistic here if we see A significant value creator, but quite disciplined considering the points I referenced relative to the strategic value creation, The financial value creation, which we're quite disciplined on and of course mindful of the regulatory environment.

Operator

Thank you, Mr. Raskin. Our next question comes from Mr. George Hill with Deutsche Bank. You may ask your question.

Speaker 11

Yes. Good morning, guys. And David, I wanted to

Speaker 3

pull on a Fred, that

Speaker 11

you just mentioned in the last comment, which was demand for digital. And I guess I would ask for demand for digital ex telemedicine. I think before you guys bought ESI, they had started to build a digital formulary. Brian talked about increased investments in technology to drive future growth. So I guess I would talk about, are any of these initiatives material yet, again, ex telemedicine?

Speaker 11

So are any of the digital initiatives It's really moving the needle at the bottom line. And I guess could you talk about where future capital is going to be deployed to grow and fill out the white space here?

Speaker 2

So First, just a calibration point. The digital formulary you made reference to transpired as we're combined entities, and I think it's a good reinforcement of Innovation. So I agree with you using that as an example of innovation. 2, I do appreciate you broadening, the leverage and the value creation of digital beyond, Although, virtual health is massive beyond that, as we look into the organization, we see significant opportunity to leverage digital capabilities I'll cite 2 examples just to be succinct. One of which I made reference to in terms of Supporting our customers and patients with specific, highly personalized, immediately information as they make their personal health decisions around consuming care.

Speaker 2

And I cited an example in orthopedics and musculoskeletal, Where there is a significant amount of preference and choice, that the consumer or patient has exercised and we've learned over time delivering Information that is personalized and actionable at the moment that matters when decisions are being made is mission critical and we're able to Improve value for that patient through better quality, better affordability and then share some of that benefit back to the So that's an example in the care side of the equation. On the administrative side of the equation, we talked about our ability to harness further leverage in the franchise off of shared services, As well as our continued growth of our revenue portfolio, a digital first framework is mission critical within that. We have the ability to bring more personalized services On the administrative side of the equation, both to our customers as well as to our physician partners, and most of that lies upon a digital first philosophy and framework, and we continue to invest there. On a final note, some of the CapEx that Brian made reference to goes toward both of these dimensions, whether it's in the care enablement side of the equation Or whether it's in the administrative service side of the equation, we see it as a meaningful value creator, and I appreciate you calling that out.

Operator

Thank you, Mr. Hill. Our next question comes from Mr. Ricky Goldwasser with Morgan Stanley. You may ask your question.

Speaker 12

Hi. This is Michael on for Ricky. Just a couple of really quick questions. One question about the 119,000,000 Charge related to the strategic plan to drive operational efficiencies. Curious, what's the expected size of the cost savings, Cadence, timing, is that baked into guidance?

Speaker 12

And then second question on the MA rate notice. I know you addressed it a couple of times on the call, But just given how strong it was, just and 22 membership perhaps falling a bit short of expectations starting flat, Any implications to competitive dynamics next year? Is there a preference for maybe reinvestment to benefit richness or marketing distribution channel? Thanks.

Speaker 3

Good morning, Michael. It's Brian. I'll take the first question and then David can pick up on the Medicare Advantage component. So as we announced this morning, We are taking a charge in the quarter associated with organizational efficiency and you can think of that the charge amount itself about $168,000,000 pre tax. Over time, that will run rate to a number in the $200,000,000 to $225,000,000 range and you can expect that that Full run rate will be achieved by 2023.

Speaker 3

A portion of that will come through in 2022. Of course, that won't all drop to the bottom line. A portion of that will redeployed in the form of more competitive prices and premiums out into the market. And just to give you a little more context there, I talked about automation, digitization. So a piece of this will be essentially removing unnecessary work and some of that will be personnel.

Speaker 3

There's also a significant piece in here associated with real estate. We made the decision after a couple of years into the pandemic that some sites should be closed permanently and or some floors restacks. So there's a component here associated with real estate optimization as well. David, you

Speaker 2

want to pick up on the Medicare Advantage component? Sure. And Michael, just to transition from Brian's point, I'd point you to the fact that our SG and A ratio for 2021 was a very attractive number and our outlook for 2022 is a further improvement. So back embedded in our outlook as a further improvement to the SG and A ratio. Relative to the Medicare rate notice in the 2023 environment, We view it as just macro a positive environment for us to lean into.

Speaker 2

I think to the core of your question, do we view it negatively or do we have Regret, relative to our growth posture for 2022, as we look to the rate notice for 2023, my answer to you is yes and no. Clearly, we would like more lives that are sustainable, to be able to serve, but we believe being disciplined in this, more fluid environment of 2021 and 2022 What was a better answer and better decision? And I would remind you, we're talking about numbers off of a book of business of about 550,000 lives. So within our portfolio, that's about 10% 5% of the enterprise revenue. We're able to make those trade off decisions.

Speaker 2

Looking to 20 In 2023, we see more opportunity. We see that opportunity off of our base. We see the opportunity off of our geographic expansion off the last 2 years. We see that opportunity being further enabled by the rate environment for 2023. So we're excited by that.

Operator

Thank you. Our next question comes from Kevin Fischbeck with Bank of America. You may ask your question.

Speaker 5

Great, thanks. Maybe just want to follow-up with that and maybe broaden it a little bit to the exchanges as well. I guess, I understand when you price for margin, you're going to grow below average, but MA is growing high single digits, you're flat. The Exchange is just having one of the best growth rates. We're probably going to see a year down and in both cases, you're expanding geographies.

Speaker 5

The other companies who have talked about conservative pricing are still growing. So I just wanted to see a little bit more if you can talk about both MA and the exchanges as far as What gives you confidence that your products are going to be competitive and be able to grow? And I guess when you think about 2023 growth, Are you just talking about reacceleration off of flattish or are you talking about getting back to industry level growth rates in those businesses for next year?

Speaker 2

Kevin, I appreciate your questions. 2 very different markets in 2 very different market environments. Specifically to the individual Change environment, our point of view is, adding more lives at 0 or negative margin is not a shareholder prudent posture. 2, In a marketplace that is fluid year in, year out, we've been able to prove that as that marketplace is undulated, Our discipline is played through, save for the special enrollment period that played through in 2021. Our discipline is played through in a net positive way as we've been able to build more geographies, more focus in geographies and yield a sustainable proposition.

Speaker 2

But to be very clear, Our conclusion is that adding additional lives in a marketplace that's fluid year in year out at 0 or negative margin in Capital intensive sub segment of the marketplace is not prudent. Looking forward, that marketplace will shake itself out as it has in And we see attractive growth off of our existing geographies and new geographies. Relative to Medicare Advantage, your challenge is fair. I don't resist your math for a challenge. We see that as opportunity versus downside relative to us.

Speaker 2

We've broadened our reach over the last couple of years meaningfully in terms of new MSAs as well as new counties. Our STAAR Performance is deep within the 80s on a sustained basis and our net promoter score is quite high. So the cornerstone of the value The position you need to play through remains very attractive in the marketplace. I'd remind you that we've only participated in the individual market And we've recently only participated in the individual HMO and PPO market over the recent vintage. So we looked within and said our strike zone was small, Less than 20% of the addressable market, we've expanded that to about 30% of the addressable market now, we'll continue to grow that over time.

Speaker 2

So, we look at this Current environment for both of these businesses where in 2022, we're able to be disciplined for both of those businesses and not chase low or 0 margin business And yield attractive revenue and earnings growth for the franchise and put ourselves in position for what should be a very attractive 2023 for both of those businesses with attractive, meaningful, sustainable growth outcomes.

Speaker 5

Great. Thanks.

Operator

Thank Our next question comes from Mr. Nathan Rich with Goldman Sachs. You may ask your question.

Speaker 13

Hi, good morning. Thanks for the question. Brian, I just wanted to go back to the MCR guidance for 2022. It implies I think about 50 to 200 basis points of Improvement, you noted utilization now is expected to be above baseline. And I think if I heard you right on the Q1, MLR will be up a little bit year over year.

Speaker 13

So could you maybe just talk through the tailwinds that you see over the balance of the year as it relates to MCR? Thank you.

Speaker 3

Good morning, Nathan. So I'll do my best to tackle different aspects of that question. And importantly, the guidance is on the Cigna Healthcare basis. So for purposes of comparability, it's important As you go back and look at our historical financials that we are looking at the Cigna Healthcare basis and not the prior U. S.

Speaker 3

Medical basis. But in aggregate for full year 21, we landed at 84% for the full year MCR. And to your point, the guidance is 82% to 83.5%. So take the midpoint of that, It's 125 basis points of improvement from 'twenty one into 'twenty two. So all in, As I mentioned in my comments and you mentioned in your question, we are expecting the absolute level of medical costs relative to baseline in 2022 to be similar In full year 'twenty two to what we saw in full year 'twenty one.

Speaker 3

And so we were previously assuming that there would be some level of cost abatement in 'twenty two. We are no longer assuming that. We think that's a prudent posture Sure to take stepping into 2022 in light of the year that just ended. So as a result of that, The MCR improvement year over year is attributable to both our revenue outlook, our affordability actions and some mix of So to give you a little more specificity there, if you were to decompose the 125 basis points, think of about 75 basis points of that Associated with revenue yields in excess of our cost trends predominantly in U. S.

Speaker 3

Commercial. So as Justin asked earlier about the fully insured book, We are seeing revenue yields in excess of cost trends as well as the other sub segments of that portfolio. We expect about 25 basis points of improvement to come from our Medicare Advantage book, specifically the risk adjuster headwind that we incurred in 2021 We'll fully unwind here in 2022. We've got a good level of visibility on that. And then the final 25 basis points is associated with our individual and family plans book, In particular, the special enrollment period lines that we described earlier, we expect a level of normalization in the medical care ratio from that book both from a combination of the pricing actions we took, the improvement in terms of risk adjuster coating in 'twenty two, less pent up demand and some Put that all together and you get 125 basis points from the final 'twenty one to the midpoint of our 2022 guide.

Speaker 3

Those are the big chunks I would encourage you to think about.

Speaker 6

Thanks. That's helpful.

Operator

Thank you, Mr. Rich. Our next question comes from Mr. Stephen Baxter with Wells Fargo. You may ask your question.

Speaker 5

Yes. Hi, thanks. Just to follow-up on Kevin's question on the exchanges. I guess I wanted to take a little bit more of a short term orientation about 2022. Obviously, you're working to reprice this business in what remains a pretty competitive and price sensitive market.

Speaker 5

So I was hoping you could give us a sense of How much this membership has set the decline in 2022, basically what we're going to see when you report your Q1 results? And then such because it's such a big Swing factor for 2021, are you expecting this business will be at least breakeven for 2022 within the guidance you're establishing? Thank you.

Speaker 3

Hi, Stephen. It's Brian. I'll start and then if David wants to pick up on any aspects, feel free to jump in here. So, we ended the 2020 1 calendar year with 378,000 lives. And as you know, the open enrollment period just ended a few weeks ago.

Speaker 3

So there There's still some dust to settle in terms of who will follow through with 1st premium payments. We have extended grace periods on some of the customers, etcetera. So Pinpointing the exact number is a bit of a challenge for the Q1. But for the full year, based on how the open enrollment period just ended up, we would expect to be down in the range of 20%, 25%. So you can think of the $378,000,000 that we ended at year end 'twenty one coming down by that sort of magnitude by year end 'twenty two.

Speaker 3

Into a year, there's likely to be some net attrition. So I won't try to pinpoint the Q1 number, but you can expect it will be down from the year end number and then we'll see some further Over the course of the year, based on the pricing actions we took, we've seen our competitive position slide down in most geographies. So The renewals that we did get, we were pleased with because the prices are certainly firmer than they were in 2021, which Good confidence in the margin expansion and following up on the question that Nathan just asked me, we would expect all in MCR improvement on this book of business of several 100 basis points when you think of the loss of the special enrollment period lives and the revenue yields that we were able to achieve.

Speaker 2

So therefore, margins expanding in the book to your point, not quite at but approaching more reasonably what our target margins are for the book of business, but not quite at that

Operator

Thank you, Mr. Baxter. Our next question comes from Mr. Dave Windley with Please you may ask your question.

Speaker 14

Hi, good morning. Thanks for taking my question. David, I wanted to come back to Medicare Advantage and ask What key levers do you think or what key changes do you need to make in the Medicare Advantage business to enrich benefits For competitive purposes, lower cost structure, in particular to be profitable We're closer to profitable at price points that you're talking about in the current environment. And what might Evernorth, How might you invoke Evernorth to help in that regard?

Speaker 2

So Dave, again, let's start with big picture. Big picture, The performance of that book of business as we step into 2022 has a pretty reasonable retention level. Retention points a couple of points Below where we would like it to be given the competitive environment, just less new business sales. So from a value proposition for those we are serving today, Largely off of an individual HMO chassis and increasing off of an individual PPO chassis, the value proposition resonates for those that are Consuming our services, but the new business side of the equation, a little bit more challenging given the dynamic in the marketplace. I think we always enhance the value proposition.

Speaker 2

And so to the core of your point, I would point toward 2 areas. 1, the ability to continue to accelerate and enhance The collaboration between the pharmacy, the specialty pharmacy and the payroll subcomponent of the proposition and 2, The ability to further leverage some alternative side of care opportunities, for the benefit, in this case of the senior beneficiary To deliver both better overall affordability and convenience. So you can think about that as alternative side of care being digital, Home care or extending the services that could be delivered in a coordinated value based physician relationship from that standpoint. We see both of those as net additional added value opportunities for both affordability as well as personalization for the individuals we serve.

Operator

Thank you, Mr. Windley. Our next question comes from Mr. Lance Wilkes with Bernstein. You may ask your question.

Speaker 9

Yes, good morning. Just wanted to ask a question about outlook for the Evernorth PBM sort of business and had 3 components here. 1, was interested in the amount of contribution in 'twenty one and the outlook for 'twenty two and beyond from In 'twenty one and the outlook for 'twenty two and beyond from specialty products going generic and how that's impacting margin. Then on a growth end, was interested in what's the further upside with respect to potentially penetrating the Cigna book of ASO business? And then lastly, just on Prime Therapeutics, just interested in what the outlook is as far as renewing that contract.

Speaker 9

Obviously, you've been And deepening the relationship, but just was interested in kind of how we should look at the security of that.

Speaker 2

Lance, it's David. Good morning. You packed a lot into one question. Let us try to touch upon each. I'll take the prime question.

Speaker 2

I'll take the upside on the Cigna book and I'll ask Brian to Take the specialty and specialty generic piece of the equation. First, specific to Prime, just at a more macro level, I'm not going to go Detailed renewal situation with the on the line here. But if you take 2 steps back, Prime is a great reinforcement Our orientation around partnering, our health plan business has continued to grow. I referenced previously, we've had net growth in our health plan portfolio of about 20 health plans Over the last several years, specific to Prime, we're proud to be able to serve our Prime, both organization, the Health plans within it and the members, we've been able to expand the relationship and broaden the relationship over time. And importantly, Lance, we co collaborate and co innovate with the health plans within Prime to help to drive further growth for them.

Speaker 2

So we view it as a positive and it's a reinforcement of The meaningful and attractive sustained growth we've had in our health plan portfolio businesses. As it relates to upside within the Cigna portfolio, We continue to drive leverage between the Cigna Healthcare portfolio and the Evernorth portfolio. For example, our growth recently With UPMC as an example of leverage between the two organizations, where we leverage some of our Cigna Healthcare capabilities within the Evernorth relationship, For a strategic long term partner, we were able to expand the relationship in that way. Specific to your I think the Traditional part of the way you're asking the question, I'll wrap up here is on the PBM penetration, within the Select segment, always deemed that to be fully penetrated. Within the middle market segment, The level of penetration varies based on client relationship.

Speaker 2

We see some additional penetration as having been achieved. And then within national accounts, it's an account by account relationship that is determined. So overall, we're pleased with our current state of penetration for PBM in Cigna Healthcare. It can move a little bit more, but I wouldn't You look at it as a big barometer of movement rather the leverage of

Speaker 3

the relationships like a UPMC is a great example of you're using the word penetration, we'll use the word Cross Leveraging, Cross Value Collaboration. Brian, I'll actually take the specialty and specialty generic piece. Yes. Good morning, Lance. So overall, just kind of big picture, specialty generics and biosimilars are both really important mechanisms to drive affordability for our clients and customers over They drive competition and that's a really important part of the landscape here.

Speaker 3

And specialty was a meaningful driver of our results In 2021 and it will be in 2022 in the Ever North space. So while I won't specifically size the contributions from Specialty Generics, it was a helpful Contributor over a multi year period now to our ultimate P and L for EverNorth. And as we step into 'twenty two, I mentioned in my prepared comments, Specialty will drive revenue growth in Evernorth. All in, we would expect our Evernorth growth to be within our long term targeted growth range, meaning at least 4% Revenue growth powered heavily by specialty. Specialty generics will be a part of that as will biosimilars and other Parts of the drug space.

Speaker 3

So all in, we would expect EverNorth revenue to grow at least 4% for the coming year, and we expect income growth of 5%, the specialty generics being a component of that.

Operator

Thank you, Mr. Wilkes. Our next and last question comes from Mr. John Ransom with Raymond James. You may ask your question.

Speaker 4

Hey, good morning. Thanks for going a little long, team Cigna. The question I have is if I know you guys aren't breaking out COVID costs anymore, but if we were to assume more of a normal cost, Not trend, but just a cost reset in 2023. Could you please give a zip code for what that would mean quantitatively? Thanks.

Speaker 3

Good morning, John. It's Brian. So, you're right. We found it increasingly difficult to try to segregate COVID and non COVID. And The commentary we had earlier in 'twenty one about COVID headwinds, particularly as you're finding more and more situations where an individual admitted to the hospital with one condition and then found to have COVID later on or the situation with our special enrollment period lives, It was tough to determine, is that a COVID related issue or not?

Speaker 3

So we found it increasingly difficult, which is why we talk about all in medical costs relative to the baseline. As I mentioned Earlier for full year 2021, we ran above the baseline persistently for all four quarters across the book And we've carried that assumption forward into 2022. And so you should think of that as when I say above the baseline, not 1% above the baseline, but A few percentage points above the baseline, so think of low single digit to mid single digit above the baseline. And then over time, if there's some moderation, that will provide tailwind relative to our 2022

Speaker 4

And then just one for David. I mean, just strategically, I get to Help out our benefit committee and vetting vendors and things like that. And so we've been going through this cycle. And what strikes me and we're a pretty large ASO plan. What strikes me is What we're hearing from the consultants that we use is everybody's hot on using these navigators, and I know you know they are.

Speaker 4

And so we're talking about like yet another overlay To sit on top of the PPO, which now needs to become a TPA, so you can steer and then there's quality information, we changed the number on the back of the card, so we're calling the navigator. And the reaction from our management was, gosh, this looks like it could save some money, but why do we need yet another layer on top? Why are the health plans not able to do this with all the Reserves and IT and everything that they have. And so I'm just curious, you're a large ASO player. I just wonder what your thought is long term about So planning that function or do you think that's just we're just going to add yet another function on top so that we can take 3 points out of the cost trend?

Speaker 4

Thanks.

Speaker 2

Yes. Efficient work, John, grabbing another question there. I think your question points toward the criticality of sustained innovation. And if you as I know you do, if you go back and look at the space over the last couple of decades, there continues to be Periods of time where specialists will take a slice of the value proposition, and I don't say that as being But we'll take a slice of the value proposition and try to drive super specialization within that. Typically, what that results in is either consolidation of those capabilities or accelerated innovation of those capabilities to be coordinated.

Speaker 2

So We don't think the picture you articulate is sustainable. We don't think your coworkers want to have multiple touch points coordinating them. We don't think medical professionals want multiple touch points coordinating them, but rather the theme of a navigator is totally on strategy for us. We have generations of that within our portfolio, Within different solutions that have been in the marketplace for quite some time, OneGuide capability and certain clinical team capabilities And having a digital first philosophy, which is what I discussed previously, would reinforce to you that we continue to not only expand programs, but expand the capabilities on a digital first standpoint that could be able to do the navigation for our customers in a much more coordinated way. So We view that as on strategy.

Speaker 2

We view that as part of our CapEx. We view it as part of our capabilities within our portfolio and we have multiple Positive proof points of how we've been able to convert that today, but we do not view that as an opportunity for the marketplace This is intermediate over a long period of time because that fragmentation is not sustainable. No opportunity for us.

Speaker 4

David, if I hadn't snuck in that question, you wouldn't have been able to give that answer. So I

Speaker 5

know you're happy with it.

Speaker 2

I appreciate your effectiveness, Sean. You have a great day.

Speaker 5

All right. Thank you. See

Operator

you. Thank you, Mr. Ransom. I will now turn the call back over to David Cordani for closing remarks.

Speaker 2

John reinforces that the operator's suggestions or guidelines. But John, I do appreciate it very much. We want to thank everybody for your questions and importantly your time this And before I wrap up, I just have a couple of comments. First, I want to say how appreciative and proud I am of our more than 70,000 colleagues for continuing to serve our clients, our customers and patients in Very challenging environment. We've all gained an even greater appreciation of the importance of health and well-being during this prolonged pandemic.

Speaker 2

And at Cigna, we're committed to continue to innovate To deliver more affordability, simplicity and predictability of solutions for our customers, our patients and our clients, our EverNorth and Cigna Healthcare platforms are well positioned for sustained growth and we're confident that 2022 will be another strong year for Cigna. Thanks and have a great day.

Operator

Ladies and gentlemen, this concludes Cigna's 4th Quarter 2021 Results Review. Cigna Investor Relations will be available to respond to additional questions shortly. A recording of this conference will be available for 10 business days following this call. You may access the recorded conference by dialing 866 359-three thousand seven hundred and seventy nine or 203-369-0147. There is no passcode required for this replay.

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