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Text: I'm Ralph Giacobbe, senior vice president of investor relations.
In our remarks today, David and Brian will cover a number of topics, including Cigna's fourth quarter and full year 2021 financial results, as well as our financial outlook for 2022.
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.
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-K filing and investor call on January 24, we announced changes in our segment reporting effective for the fourth quarter 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 seven Asia Pacific markets.
Effective in the fourth quarter, Cigna's results will be reported through the following three groups: Evernorth, Cigna Healthcare, and corporate and other operations.
The international health business to be retained by Cigna will join our U.S. commercial and U.S. government offerings in a new segment called Cigna Healthcare.
This segment replaces the prior U.S. medical segment.
Second, regarding our results.
In the fourth quarter, we recorded an after-tax special item charge of $119 million 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.
We also recorded an after-tax special item charge of $70 million or $0.21 per share for integration and transaction-related costs.
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 second quarter 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.
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 remain 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.
Today, I'll share a perspective around our 2021 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.
With that, let's get started.
In 2021, we grew full-year adjusted revenues to $174 billion, a second consecutive year of growth above our long-term target.
We delivered full-year adjusted earnings-per-share growth of 11% and to $20.47, and we returned over $9 billion to shareholders in dividends and share repurchases.
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 two 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.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 to expand that portfolio.
Additionally, we are positioned so that accelerated growth in one area can compensate for temporary pressure in another business within our portfolio.
We see this as extremely valuable in a dynamic environment.
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, governmental agencies, and healthcare delivery system partners increasingly recognized the value of our health services, including in our specialty pharmacy business, which I'll discuss in more detail in just a moment; in our virtual health capabilities, which have been expanded through MDLIVE 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.
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 Perry customers within the individual business.
These included the impact of elevated COVID costs for testing treatment of vaccines.
The elevated trend continued throughout the year.
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 and complementary nature of our portfolio enabled us to exceed our revenue and earnings per share outlook and return over $9 billion 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 capabilities to respond to three forces that we believe are fundamentally reshaping the future of healthcare.
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 one of the most promising areas for medical innovation in the coming years.
And we're seeing good 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.
By 2025, for example, 66 biologic drugs currently in the market will have the patents expire, opening the door for increased biosimilar competition and an increasing opportunity to decrease healthcare spending by an estimated $100 billion.
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 Accredo capability, which provides differentiated specialty pharmacy care for a number of specific conditions.
I'd also highlight that today, specialty pharmacy already drives only one-third of our North 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 business.
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.
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 MDLIVE platform as well as expanding our behavioral care network.
We know how important it is for both patients as well as clients.
Our Evernorth 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.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 to 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.
In the U.S. government business, as we've noted previously, we are operating in a more competitive environment stepping into 2022.
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 Star's ratings are very strong, and we 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 for 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.
For 2022, we entered three new states and 93 new counties.
With these markets, for example, we have the ability to reach an additional 1.5 million additional customers.
In international health, we are sharpening our focus, and we'll continue 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 establishing our joint venture with the nib Group in Australia.
Now taken as a whole, 2022 will be another year of attractive growth for our company.
Our earnings per share outlook of at least $22.40 and the increase of our quarterly dividend by 12% reinforces the sustained growth and strength of our businesses.
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 three areas of continued focus here.
First, in U.S. 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.
Second, 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 supplemental benefits business in seven markets reinforces our discipline to focus on the health portion of our portfolio.
Now to wrap up.
Looking back at 2021, our business performed in a dynamic environment.
We delivered adjusted earnings per share of $20.47 and returned over $9 billion of capital to our shareholders in dividends and share repurchase.
2022 will be another year of growth across our business, and we will continue to invest in innovation to position us for sustained long-term growth.
Today, I'll review key aspects of Cigna's fourth quarter 2021 results, and I'll provide our outlook for 2022.
Key consolidated financial highlights for full year 2021 include adjusted revenue growth of 9% to $174 billion or growth of 12% when adjusting for the sale of the group disability and life business.
Adjusted earnings of $7 billion after tax and adjusted earnings-per-share growth of 11% to $20.47.
We delivered these results despite an elevated medical care ratio in the quarter partly driven by COVID-19-related claims.
Our enterprise revenue and earnings per share results were slightly better than our expectations, reflecting the resilience and breadth of our portfolio, with particularly strong performance in Evernorth.
Regarding our segments, I'll first comment on Evernorth.
Fourth quarter 2021 adjusted revenues grew 15% to $35.1 billion, while adjusted pre-tax earnings grew to $1.6 billion.
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 its long-term growth targets.
medical segment plus our retained international health business.
Overall, fourth-quarter adjusted revenues were $11.2 billion, adjusted pre-tax earnings were $472 million and the medical care ratio was 87%.
During the fourth quarter, 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 fourth-quarter costs are attributable to three primary areas: higher stop-loss claims, particularly in policies with lower attachment points that were triggered by the cumulative impact of COVID and non-COVID costs throughout the year; continued pressure on our individual business, particularly the special enrollment period customers who were added in mid-2021; 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 the medical care ratio of 84%.
The unfavorable fourth 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.
This 2022 medical cost outlook is now higher than our previous expectations.
In specific to stop-loss, we assume the pressure experienced in the fourth quarter will persist in 2022, and we will take appropriate future pricing 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.S. commercial enrollment and retention than previously expected in our fee-based business and incremental affordability actions, which I'll elaborate on in just a few moments.
We ended the year with 17.1 million total medical customers, an increase of approximately 430,000 customers for the full year.
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 fourth-quarter adjusted loss was $115 million and now includes positive earnings contributions from our international life accident and supplemental benefits businesses held-for-sale pending divestiture.
As Ralph noted, during the fourth quarter, we reported a special item charge of $119 million 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 earnings per share growth.
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 second quarter of this year.
In total for the company, we expect consolidated adjusted revenues of at least $177 billion, 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 $6.95 billion or at least $22.40 per share, consistent with our prior earnings per share 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 $6.1 billion.
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.
For Cigna Healthcare, we expect full year 2022 adjusted earnings of approximately $3.9 billion.
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.
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.
We expect the 2022 medical care ratio to be in the range of 82% to 83.5%.
As I noted earlier, this outlook assumes total medical costs 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 Evercore subsidiary on an incorporating site of care review to our existing processes.
These improvements encourage the use of non-hospital settings, which can substantially reduce cost for customers while increasing patient satisfaction.
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 MDLIVE 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.
In 2021, we finished the year with $7.2 billion of cash flow from operations.
Additionally, we returned over $9 billion 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 $8.25 billion of cash flow from operations, up more than $1 billion 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.
We expect to deploy approximately $1.25 billion 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 $1.4 billion to shareholder dividends, reflecting our meaningful quarterly dividend of $1.12 per share, a 12% increase on a per-share basis.
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 million to 312 million shares.
Year to date, as of February 2, 2022, we have repurchased 2.5 million shares for $581 million.
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.
Our 2022 outlook reflects meaningful contributions from each of our two 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 earnings per share commentary.
Finally, as Ralph noted, we are looking forward to speaking with you in more detail at our upcoming Investor Day in June.

user
adjusted income from operations is projected to be at least $6.95 billion in 2022, or at least $22.40 per share.
sees 2022 adjusted revenues at least $177 billion.
sees 2022 medical care ratio 82.0% to 83.5%.
qtrly special items include an after-tax charge of $119 million, or $0.36 per share, related to a strategic plan.
board of directors declared a 12% increase in the quarterly dividend rate, to $1.12 per share.

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