Cigna Aktie

Welcome to the Cigna Group Investor Day. Please welcome Ralph Giacobbe.

Good morning. Welcome to the Cigna Group's 2026 Investor Day. I'm Ralph Giacobbe, Senior Vice President of Investor Relations. And on behalf of our leadership team, we want to thank you for joining us today. We're excited to share how we've deliberately shaped our portfolio to position the Cigna Group where health care is growing and where we can create the greatest value.

Today, you'll hear about our lead to one vision, driving greater personalization for all our members, but the greatest impact on those with complex conditions where we have a unique and differentiated set of assets and capabilities. We'll delve into our 3 largest businesses, Evernorth Specialty & Care Services, Cigna Healthcare, and Evernorth Pharmacy Benefit Services and how will drive profitable growth and add value across the system. You'll hear about how our advances in data, technology and AI. Together with our clinical capabilities enable us to deliver more personalized services, better outcomes and greater affordability for patients and clients. And will discuss how the strength of our businesses, together with our operational execution, and disciplined capital deployment supports our attractive long-term operating earnings growth and shareholder value creation. We look forward to your engagement throughout the day.

Now before we begin, I would note that today's presentation is being webcast live and a full set of presentation slides are posted on our Investor Relations website. Also I want to remind you that we will be referring to non-GAAP measures and making forward-looking statements, relevant definitions, reconciliations and disclaimers are available in the presentation slides. Actual results may differ materially.

With that out of the way, let's get started.

Please welcome Brian Evanko.

Thanks, Ralph. Good morning, everyone. Thanks for joining us for the Cigna Group 2026 Investor Day. I'm Brian Evanko, President and CEO of the company. And while this is my first Investor Day as CEO, I have been with the Cigna group for close to 30 years. And we have a lot to talk about today. We look forward to taking you through some of the great things we're doing to create value in the market as well as for our shareholders. We're going to talk today about the strong foundation of the Cigna Group, the clear strategy that we've developed for success in the future as well as our proven ability to execute. We look forward to today's dialogue with all of you.

I'm going to head of a few key areas here in my opening remarks. First, our track record of evolving the company through different periods of environmental change. Secondly, the portfolio we've deliberately constructed to deliver results today as well as grow into the future. Third, the capabilities that we've built up over a period of time that are differentiated and increasingly difficult for others to replicate. And finally, the way we execute with discipline, both operationally and financially and how all that translates into a long-term shareholder value proposition. So let's start by talking about our track record over the past decade. The last 10 years has been characterized by what I would describe as extreme environmental disruption, right? We had a global pandemic, hopefully, the only one in our lifetime. Affordability has reached crisis levels of health care, significant changes from a policy standpoint, I think all the government-sponsored health care disruption, changes from a regulatory standpoint on both the medical side and the prescription drug side. Overall that, the Cigna group has made deliberate decisions on where we can create the most value in the market.

We started a decade ago is predominantly a health plan focused on serving employers. In 2018, we made the decision to combine with Express Scripts , which gave us instantly a leading health services platform, with both Express Scripts or PBM as well as Accredo, our specialty pharmacy. Subsequent to that, we made strategic choices to divest certain businesses that were noncore, such as our group life and disability or our international supplemental operations. And we made a decision to divest businesses where we didn't feel like we had a competitive advantage, such as our Medicare operations last year. And along the way, we added other capabilities, specifically to intensify our focus around complex care needs. Think some of the investments we made in specialty pharmacy capabilities over the past 2 to 3 years. So this just demonstrates a track record of disciplined portfolio management, to make sure the company can succeed and thrive over the long term. So what resulted from this is a larger company, but a more focused company.

So we've actually transformed the company from 10 years ago being a relatively small health benefits focused company to today, one that's -- has the benefit of 3 strong growth platforms, our specialty pharmacy capability in Evernorth, our broader pharma services platform within Evernorth and Express Scripts and Cigna Healthcare, squarely focused on serving employers. All of these businesses have an emphasis on complex care, and that is where spending in the health care system is increasingly concentrating. So we've increased exposure to where there's attractive long-term secular trends. Simultaneously, we've reduced exposure to those areas we do not feel we have a competitive advantage. So all of this demonstrates a consistent track record to periods of extreme change. You would have seen this morning, we reaffirmed our 2026 financial outlook for all key metrics. So we're tracking to deliver 14% compounded EPS growth over the last 10 years despite an extremely disrupted external environment from the pandemic economic shocks, significant changes in government-sponsored health care programs and affordability pressures. That consistency comes from the durability of the company, our willingness to adapt as well as the way we execute with discipline.

Throughout that time period, many others in our sector had substantial financial resets and considerably more variability in their performance. So our disciplined execution and the deliberate choices we made about our portfolio have guided us since our last Investor Day. So it was about 2.5 years ago, we were last together for Cigna Group Investor Day.

Since that time period, we've navigated a very dynamic environment. And through that, our Specialty and Care business now represents 37% of the company's total earnings, up from just 30% 2 years ago. In Cigna Healthcare, our Select segment, which represents employers with 500 and fewer lives, we've grown the customer base by 12% since our last Investor Day. That's well ahead of the industry average, and we've continued to return a substantial amount of capital to shareholders.

Additionally, we've been able to navigate some significant policy and regulatory changes. A good example of this. Last year, we introduced our revolutionary new signature model in pharmacy benefit services. Rebate free, the only company that's introduced that fully transparent, fee-based, simple guarantees patients the lowest possible out of pocket. This model will fully scale starting in 2028, and it's where the industry is headed. So we're proud to take a leadership position by stepping away from the competition with our signature offering.

We also were able to grow our EPS every year since our last Investor Day, which is a differentiated result relative to our sector. So our portfolio has continued to shape itself around specialty pharmacy, broader pharma services and employer sponsored health care.

Now as CEO, there's a few areas in particular that I'm focused on to ensure the long-term sustainability of the company. One, driving customer personalization with a particular emphasis on those who have the most complex health care needs. A second area is how we use data individual context with our customers, clinical capabilities, advanced analytics and AI to drive that personalization. And finally, we'll continue to invest in our people and in our culture. All those things will ensure the long-term success of the Cigna Group. We have a strong foundation to build from. We have breadth across 3 strong growth platforms, balance and all of this supported by scale.

So today, Cigna Health care represents about 40% of the company's earnings. And Evernorth, our Health Services platform represents about 60%, of which 37% is specialty and care. So we have multiple earnings engines for growth. And they're mutually reinforced through clinical data customer relationships and distribution that are across enterprise in nature. So these deep relationships give us the ability to operate at scale. And in fact, today, we have some 22,000 employer relationships.

Additionally, we have industry-leading access to limited distribution drugs in our Accredo specialty pharmacy with 330 in County. So this strong foundation across the Cigna group positions us well for the future needs of the health care system. Right now, I would assert that the environment for health care is at an inflection point, and the current trajectory is unsustainable. Challenges are not just affordability but also rising consumer expectations. We're seeing health care costs grow faster than inflation, faster than wages, faster than the economy. The average hospital stay is up 280% since 2000. And while new prescription drugs have brought cures to many patients and significant innovative benefits that comes at a cost, with newly approved prescription drugs over the past several years being in the $200,000 to $400,000 basis on a median list price.

Additionally, consumer expectations continue to increase. Relative to other parts of their life, people want health care to feel convenient. They want it to feel transparent. They want it to feel personalized. They want it to feel easy. The silver lining in all of this is that the explosion of data, the advancements of technology, AI, advanced analytics, now make things possible that were not possible 5 years ago or 8 years ago relative to meeting those increasing consumer needs. Additionally, chronic and complex spending now represents the majority of health care costs. And it's where costs are growing the fastest.

So all these trends, all these market forces have shaped the Cigna Group's forward-looking strategy. So this is an important slide because it gives you a little bit of background for what the rest of the day will go deeper on. Lead to One is our single unifying vision that drives all 60,000 plus of the Cigna Group colleagues. The essence of Lead to One is driving personalization at scale. Personalization at scale for all the customers we serve, all the patients that we serve, all of those we are privileged to serve. So this includes supporting those who are currently healthy, all the way through to those with the most clinically complex health care needs. When we achieve this, and we deliver personalization at scale, it will result in better affordability as well as improve customer experiences for those dealing with the health care system. And this vision is enabled by 3 things. One is our strategic growth framework. So you're going to hear from a number of our leaders today who are going to use our strategic growth framework to bring this to life in terms of how in each of our businesses we execute against this. Secondly, one team. All of our colleagues around the world are oriented around serving our customers holistically, serving each patient as a complete person. And finally, Accelerate to One, which is our newly announced multiyear set of modernization and productivity initiatives. Ann will cover this in more detail when she talks about our financial update later today.

So our Lead to One vision, is driving personalization at scale, and it helps all customers across the entire clinical continuum. So for healthy individuals, we strive to provide the right preventative action at the right time. for those at risk, identify early warning signs before they become downstream problems. For those who currently have chronic conditions, it might be helping them stay adherent to their drug treatment protocols. And for those with the most complex care needs, coordinating across multiple providers. They may see primary care physicians and specialists or clinical coordination across the medical plan, the pharmacy plan and the behavioral health. All of these integrated needs are important for the most clinically complex populations. So our Lead to One vision aspires to serve every customer across the entire clinical continuum. But the largest potential impact on both cost and health outcomes is for those patients who have the most clinically complex needs.

This is another important page because it provides some more context when we talk about complex care, which is the basis for many other things we'll discuss today. It's indisputable. Complex conditions are shaping the future of health care. Currently, just 8% of all patients have complex care needs, but it represents 55% of the total health care spending. So coordination is critically important for each and every one of these patients. Costs are increasingly concentrated in these complex conditions. Additionally, drug spend is becoming a greater and greater share of total health care spending. And we're seeing complex drug innovation continuing to grow with most of the drugs in the drug development pipeline right now being high-cost specialty medications. So this is where our portfolio, our expertise and our infrastructure has been built to deliver value into the market.

So our intentionally built portfolio leads to a high percentage of the health care spending that we impact being concentrated in complex care. And when I say complex, here, I'm talking about individuals who may take a specialty medication, they may see multiple providers, a primary care physician as well as specialists and they may require clinical coordination across their medical plan, their pharmacy plan, their behavioral health plan. A good example of this is the photo on the screen there of Kelly. Kelly has alpha-1 antitrypsin deficiency, which is a genetic disorder that can lead to lung and liver damage. Each of our businesses impact those with complex health care needs. Specialty and care, 100% of what we do is complex health care. Every single one of the patients we serve has a complex health care need.

In our Cigna Healthcare business, about 55% of all the spending we impact is associated with complex health care needs, particularly important for those who become high-cost claimants. And our industry leadership position in stop-loss makes this especially important for us when employers seek to provide budgetary protection against large claims. And in our pharmacy benefit services, about 70% of all of the spending that we impact is associated with complex health care needs. Typically, these are the high-cost branded drugs, which represent a minority of the prescriptions, but a high percentage of the spending. We're able to negotiate very attractive discounts from the drug manufacturers on these high-cost branded drugs and wrap that with clinical programs to ensure that patients stay adherent to their treatment regimen.

So all of this allows us to drive affordability and personalization at scale. And we're well positioned for growth across all of these business units. Each of our 3 growth platforms operate in large addressable markets today, and they have attractive income growth outlook through 2030. Again, when Ann gives you the financial update later, she'll take you through the building blocks of these income growth projections through 2030. You'll note that our Specialty and Care platform represents the highest percentage growth rate from now through 2030. And we anticipate income growth in each of the 3 growth platforms. And importantly, the value that we create is both within each of the businesses, but also as mutually reinforced by cross enterprise capabilities. We deliver all of these results every single day through our strategic growth framework. So throughout the day, we'll bring our Lead to One vision to life through this strategic growth framework. And 3 pillars here, 3 elements of it. The first is delivering core growth. Here, you can think about the strong foundation and the deliberate shape portfolio that we've built over a period of many years. Secondly, how we leverage distinct capabilities the complex care assets that we've built up over decades and the clinical expertise matched with the advanced analytics and AI. And finally, how we execute with discipline, both operational excellence, but all the financial discipline from the standpoint of capital stewardship.

So I'm going to spend a few minutes on each element of the strategic growth framework to go a little deeper. We deliver core growth in a number of ways today. One, we deepened our services to meet consumer needs. A good example of that would be the Cigna Healthcare AI-powered virtual assistant that we increased or the new specialty offerings that we put to the market the last couple of years. The second way is through transforming to meet evolving market needs. I talked earlier about our pharmacy benefit services signature model. You'll hear more about that from Adam later this morning. We also introduced in July our new pharmacy forward innovation in Specialty and Care, which is reducing the time to therapy in half by taking out many of the manual touch points using the power of our clinical expertise with modern technology. A third way we deliver core growth is through expanding our distribution channels. A great example of this is in CuraScript, which is our specialty distribution business, already $25 billion of revenue today that growing double digits for many years in a row. Matt Perlberg, will take you through a little more of the details on that later. And then finally, we continue to expand to new buyer groups. So a great example of this is Accredo, which is our industry-leading specialty pharmacy. Increasingly, it's being included in unaffiliated PBM and payer networks because we have great drug access and great patient experiences. Multiple avenues here for delivering core growth.

Next, I'm going to go a little deeper on what we view as our unique capabilities to deliver value in the market on a differentiated basis. And these are increasingly difficult for others to replicate. So on this page, I've just selected a handful of unique capabilities. These are all specific to a complex care orientation. The differentiation that you see on the page has been built over a period of many years. For specialty pharmacy. We have a network of clean rooms that's extremely difficult to replicate. Industry-leading access to limited distribution drugs over 330 today and our specialty distribution capabilities, which are particularly impactful for provider administered specialty drugs. In Cigna Healthcare, we have expertise in high-cost claimants, which is very important given the growth in high-cost claims across the health plan business. and for pharmacy benefit services, the ability to negotiate very attractive unit costs on high-cost brand drugs and wrap that with clinical programs such as Safeguard Rx to ensure that patients stay adherent. So all these capabilities end up driving better outcomes and value creation into the market.

So to go a little deeper on the expertise that we've developed in complex care to make sure there's a good understanding of this. Our strategy allows us a better understanding of the underlying drivers of complex care because in health care, complexity is very rarely driven by one factor. Typically, patients have multiple coexisting conditions, or they're taking specialty drugs and nonspecialty drugs, or they're seeing a primary care physician and a specialist or they require coordination across their medical, pharmacy and behavioral health plans. So we engage across the patient's entire health care journey. We're able to address root causes and not just the visible symptoms. The ability to identify those signals, convert them to insights and influence health outcomes is what's differentiated here. And the key to all of this is taking the wealth of data we have in converting it through to personalized actions. And we do this through what we call our health intelligence engine.

When I say health intelligence, I'm talking about taking the data we have, the clinical expertise, the individual context that we have on each of the customers and patients who we serve, converting that to insights and then personalized actions. This is a key enabler of our Lead to One vision, which is driving personalization at scale. And we have a really broad data set. It spans medical, pharmacy, behavioral health, dental. We're able to take that and generate new data with each customer interaction that we have, whether it's in a call center, whether it's each time they claim. So importantly, these differentiated assets that we've built up over a period of time play a key role in converting this through to execution. And again, the result here, better health outcomes, improved affordability, better customer experiences with the health care system. Now related to all of this is a thoughtful approach to how we address innovation and how we think about partnerships.

So within the Cigna Group, we've built up an innovation ecosystem that's oriented around deliberate choices when we build, when we buy and when we partner, all meant to drive value faster. So we approach innovation with discipline and pragmatism. And at the end of the day, when we decide to build or buy, it's because we see an advantage from a differentiation standpoint or we believe there's value and ownership. Conversely, we partner where others can drive value faster or more cost effectively. So a good example of that right now is frontier AI models. Others can -- we can partner with others who can do that more effectively than we can. So we foster an environment inside the Cigna Group to test, integrate and scale innovation. Now all the capabilities I just walked through the last several minutes are important. They create more opportunity. But disciplined execution is the key to bringing this to fruition.

Our results demonstrate over a long period of time, a disciplined track record of execution. That includes operational excellence, which shows up in strong client retention, as well as strong customer experience relative to Net Promoter Scores and other measures of customer satisfaction. And we're working across the organization to simplify, streamline decision-making and improve efficiency. So today, we're announcing a $3 billion multiyear efficiency and modernization set of initiatives. And again, Ann will unpack this a little bit further later. We also continue to generate very strong cash flow, which gives us strategic flexibility. And we employ a capital-light model. So we continue to reinvest in ourselves first and foremost, but have enough free cash flow that we have a multifaceted approach to capital deployment. Now this execution orientation is only possible if we have great people and a strong culture.

Our culture is oriented around long-term value creation. And as I said earlier, operating as one team, one team serving customers holistically serving patients holistically who we have the privilege to serve. And there's a few principles that are important about our culture. We emphasize both purpose and performance. We emphasize serving customers, but also the communities where we live, work and play. We focus on business unit expertise, but also in enterprise mindset. And as CEO, I'll be focused on continuing to strengthen this culture to accelerate our impact and a good example of where that focus will come through is in our Lead to One vision, how we can accelerate progress in delivering personalization at scale. And a good example of this is how each of our 60,000-plus colleagues embrace the power of data, clinical expertise, modern technology and advanced analytics and AI to convert our Lead to One vision to reality.

So we are investing in a learning and development journey for all the colleagues across the Cigna Group to ensure we're prepared to execute against our Lead to One vision. Additionally, we continue to get back to the community. I'm proud to say we had 114,000 volunteer hours just last year. And today, we're announcing a new $10.5 million commitment to support patients who have complex health care needs and their caregivers. So our culture emphasizes accountability, innovation, collaboration and importantly, a disciplined focused execution. So when you combine everything I just went through, delivered portfolio shaping, differentiated capabilities, an orientation around execution discipline and a strong culture, the financial proposition is clear. We are well positioned over the long term for durable long-term EPS growth.

Our portfolio is aligned to the trends that are reshaping health care. We have and will continue to drive transformative change in the market, and we're confident in our ability to deliver 6% to 9% average annual income growth through 2030. Plus, our continued disciplined capital deployment, which will add 4% to 5% of EPS accretion annually. So in total, we expect 10% to 14% average annual EPS growth through 2030, plus an attractive shareholder dividend that currently yields over 2%. So today, you'll hear from a number of our leaders about how we will execute against these specific goals. Our leadership team has been built for this journey. We have expertise across the health care system from clinicians to relationship experts to those who have deep expertise in the supply chains.

Our enterprise leadership team has over 14 years of experience at the Cigna Group on average. So we understand the company's strengths. We have institutional knowledge and yet we also bring an outside-in set of diverse perspectives. But most importantly, our team is aligned around one strategy, one set of priorities and has one orientation to execution. So as I move to close, I'd like to leave you with why we see the Cigna group as being such a compelling long-term investment. We've positioned ourselves in the areas of health care, where needs and spending are concentrated today and growing in the future. We have differentiated positioning in complex health care, in particular.

Our Lead to One vision is a clear unifying destination for all of our employees to deliver personalization at scale. -- for all the customers and all the patients we have the privilege to serve. We have a deliberately shaped portfolio with strong business unit expertise, but also mutually reinforcing enterprise capabilities. And we have a strong track record of executing both operationally and financially. We're also not relying on any one single market trend in the future, one single future innovation to deliver against these results. So all these capabilities taken together position us for durable growth and long-term shareholder value creation. So thanks for your time. I'm going to turn it over now to the team who's going to bring this strategy to life for us.

Matt?

Please welcome Matt Perlberg.

Good morning, everybody. I'm Matt Perlberg, President of Evernorth Pharmacy and Care Delivery and EVP of Customer Innovation at the Cigna Group. It's great to be with you all. I've been with the company for about 13 years, and I've had the privilege of leading pharmacy and care delivery for the past 5 years. This morning, I'm going to talk to you all about the specialty market overall and why we are uniquely positioned to deliver sustained attractive growth. We're going to cover a lot of ground this morning, but there are 4 key things that I want you to take away from this presentation. First, specialty is a large, fast-growing market where we deliver personalized care to patients with complex conditions. Second, specialty is a growing contributor to the earnings of the Cigna Group. Third, we are the leaders in specialty. We have differentiated assets and capabilities that are very difficult to replicate. And then lastly, we have considerable runway to expand our addressable market, particularly in the medical benefit space.

To understand why we're so well positioned, it's helpful to look at the breadth of our specialty ecosystem. We have a number of different businesses, and we serve a broad range of stakeholders, including over 1 million patients. Collectively, our businesses generate over $100 billion in annual revenue. We have a broad national footprint. We have leading access to medications. We have deep relationships across the health care ecosystem. And we have a track record of delivering strong results. Over the last 2 years, since our last Investor Day. We delivered strong earnings growth at the high end of our range. We expanded access to generics and biosimilars. We expanded access to limited and exclusive distribution drugs. We grew our footprint and we have enhanced our capabilities. As a result of all of that, specialty now represents a greater portion of the Cigna Group's total earnings.

Now before I go much further, I want to take a step back. And I want to talk about what we mean when we talk about specialty and how specialty ties to our broader Lead to One vision. First, worth noting, every specialty patient has a complex condition. And specialty drugs are those that are used to treat patients with those complex conditions like MS or hemophilia or cancer. Very often, these are infused or injectable medications. They'll typically have strict storage and handling requirements. The specialty pharmacies who treat these patients do much more than just dispense drugs. At Accredo, our industry-leading specialty pharmacy, we deliver highly personalized patient care. We have teams of clinicians, nurses, pharmacists and more, who deliver round-the-clock care for patients. This personalized care and specialty really matters.

Let me give you an example. There's a condition that we treat within specialty called hereditary angioedema or HAE. There's a picture on this slide of a single 30-day prescription for HAE. Take a look at that. A typical retail pharmacist. They could go their entire career and never see an HAE patient never. Our clinicians, they treat these patients every single day. The medications and specialty are also often quite costly. Specialty drugs can cost hundreds of thousands or even millions of dollars per patient. As a result, Specialty is an important and fast-growing part of health care. Specialty drugs are now a roughly $480 billion market, growing in a high single digits each year. Several factors are driving this growth. First is a wave of complex drug innovation. The specialty pipeline remains quite strong. We expect about $100 billion in sales from new products launched by 2030. Second, we see growth in existing medications. Since 2000, specialty drugs have nearly doubled the number of conditions that they treat. And then lastly, we continue to see growth in generics and biosimilars. Generics and biosimilars offer savings opportunities for patients as well as plan sponsors.

We've already seen several large generic and biosimilar launches, HUMIRA and STELLAR to name a few and yet we expect about $100 billion in annual spend to face new competition by 2030. Within the broader specialty space, patients can be treated under their pharmacy benefit or their medical benefit. We have strong and growing positions in each. And as I'll touch on in a minute, that's a differentiator for us. Let me first start with the pharmacy benefit. This is about 60% of the overall market. It is growing in the high single digits each year. It typically includes drugs which are self-injected in a patient's home or drugs covered under Medicare Part D, like HUMIRA. We are leaders in this space. We serve about 1/4 of the pharmacy benefit part of the market, primarily through our specialty pharmacy, Accredo. Accredo treats over 1 million patients with over 8 million specialty prescriptions annually. Accredo generates about $80 billion a year in revenue. Worth noting, of that $80 billion, about 40% comes from sources outside the Cigna Group.

So outside Express Scripts, outside Cigna Healthcare, patients, payers, providers, manufacturers, they choose us because of our differentiated capabilities, and I'm going to talk about those in a minute. The other 40% of the market is medical benefit space. This space is growing in the low double digits. It typically includes drugs which are infused in a provider setting, where drugs covered under Medicare Part B. like oncology infusions. We compete here by serving health care providers and helping those providers deliver specialty care. The largest of our businesses in this space is CuraScript, our specialty distributor. CuraScript serves over 12,000 health care providers. We deliver complex medications to physicians' offices, hospitals, health systems and infusion centers. CuraScript generates about $25 billion a year in revenue. To put that $25 billion in perspective, if CuraScript was a stand-alone company, it would be a Fortune 200 company on its own. We also have several businesses that help hospitals and health systems treat specialty patients.

Last year, we acquired CarepathRx. Carepath provides outpatient and home infusion services on behalf of hospitals and health systems, and we invested in Shields Health Solutions. Shields is the leader in helping hospitals and health systems run their own specialty pharmacies. As we look towards the future, we expect outsized growth in this medical benefit space. So stepping back and looking at the whole market, how do we access all of this growth? Well, our growth strategy is based on 3 key capabilities. And what I'm going to do next is I'm going to talk about each of these capabilities. I'll talk about how we differentiate today and how they drive our growth going forward. First, let me unpack our clinical and patient experience leadership. We have a clinical model in our specialty pharmacy Accredo that we have built and enhanced over decades. A hallmark of that model is that we organize patient care by disease state.

We have 15 therapeutic resource centers, or TRCs, where our clinical teams specialize by disease. So we have a TRC for blood disorders. We have one for neurological disorders. We have one for oncology and several others. In many ways, our specialty pharmacy operates like 15 smaller pharmacies within a much larger ecosystem. This gives us the benefits of being large and small. So we have deep levels of personalization, but we can deploy that personalization nationwide. We also have a leading clinical team. It includes over 1,000 specialized pharmacists. It includes dieticians, social workers, and it includes our team of more than 850 field-based infusion nurses. These are highly trained, specialized nurses. They are experts in their field. They deliver care in patients' homes in provider settings and they are in their local communities. Nearly 90% of our patients live within 1 hour of one of our nurses.

Unlike many others, we employ our nurses directly. This gives us a much better and more coordinated level of patient care. It also helps our patients form relationships with their nurse that can, in some cases, literally last generations. If you are someone with one of these complex conditions, that level of personalized care from your caregiver really matters. The second key capability is our supply chain and operations advantage. First and foremost, we have leading cost of goods. Because of our capabilities, our reach, our expertise, we buy drugs and serve patients more efficiently than others, full stop. In addition, we have leading distribution capabilities through CuraScript. Earlier, I mentioned that CuraScript is a $25 billion a year business. Well, CuraScript has been growing at about 20% per year for the past 5 years, helping us reach even deeper into the supply chain.

Then we also have leading operations capabilities. We have over 30 care delivery sites. And we have 4 clean rooms. These are highly sterile environments where we safely mix and compound some of the most complex drugs. It can take years to build, license and operationalize one of these clean rooms, not to mention all of the technical expertise to run one on a day-to-day basis. Most pharmacies do not have a clean room. Ones to do, maybe they'll have one. We have 4 of them, and they're deployed across the country so that we can reach patients nationwide. But rather than just hear it from me. I'd actually like to take you inside one of our clean rooms. And what I want you to do is pay attention to the level of personalized care that we can deliver for patients with the most complex conditions. Let's roll the video.

[Presentation]

Thanks. As you can see, these clean rooms are pretty special, and they're one of the many ways that we personalize care for patients every single day. The final capability that I'll touch on is our leading access to medications. In the specialty space, manufacturers often choose one or a limited number of partners to treat patients on their products. Remember, these drugs are very complex. Manufacturers cannot risk choosing the wrong partner. They need a partner with best-in-class clinical capabilities. They need a partner with broad national reach, and they need a partner that can personalize care for each patient on each drug. We do this better than anyone. That's why at Accredo, we are the leader in access to limited distribution drugs. We have access to over 330 limited distribution drugs. This includes more than 30 products available exclusively at Accredo.

And just like Accredo is the leader in access to limited and exclusive distribution drugs, CuraScript is a leader as well. Manufacturers value that we are a one-stop partner. We can treat patients under the pharmacy or medical benefit space regardless of where they access their care. Each of these capabilities that I mentioned, they don't just operate on their own. They come together to create a flywheel that gives us a durable competitive advantage. Let me give you an illustration as to how this works. The better clinical care we provide, the more access to drugs we win. The more access to drugs we win, the more patients we are in the right to serve. The more patients we are in the right to serve, the better our supply chain and operations advantage, and we can use that advantage to return value to our customers as well as invest in additional capabilities. That's the flywheel. That's why we've built a leadership position over multiple decades, and it's why we're confident we will continue to lead going forward. And yet we are not standing still. We're continuing to innovate and execute for the future.

And there's 3 areas of innovation that I'm going to touch on. One is around technology, and others around our footprint and another is around new solutions we're bringing to market. First, let me unpack technology. We recently brought to market a new AI-powered program that will help us deliver even better patient care. It's called Pharmacy forward. It will help us get patients started on therapy much faster, enhance the care our clinicians provide and allow us to deliver even more personalized care. This is one part of our broader health intelligence engine, and you're going to hear Katya talk about that a little bit later. Second, we are growing our footprint. We're building new sites. We're expanding existing sites. As you heard Dave mention in the video, we are even building a fifth clean room. This will create capacity for millions of new prescriptions and help us keep up with all the rising demand that we see.

And then lastly, we're bringing new solutions to market. I'll give you a couple of examples. One that we are really excited about. We are launching a channel expansion alongside CuraScript called Evernorth wholesale distribution. Evernorth wholesale distribution will allow us to gain access to new medications and help us grow our business with new customers as well as existing customers. Second, we are bringing together pharmacy and medical benefit capabilities and improving options for patients. We recently brought to market a new pharmacy network whereby patients can choose whether to access care in their home through Accredo or a provider setting overseen by shields. We have about 2 million lives currently enrolled in this network. By January 1, we expect to expand that to about $6 million. And then lastly, we are creating new customized programs for manufacturers, and there's lots of different examples I could cite here.

But rather than hear it from me, I'd actually like you to hear it from one of our manufacturer partners. This is a manufacturer that recently brought a new oncology product to market, and they chose Accredo as their exclusive specialty pharmacy. I want you to listen to them talk about why they chose Accredo and the differentiated capabilities that we have. Let's roll that video.

[Presentation]

What you just heard from Sylvio is one of the many ways that we personalized care for patients every single day. So I know I covered a lot. Earlier, I said there were 4 things I wanted you to take away from this presentation. First, Specialty is a large, fast-growing market where we deliver personalized care to patients with complex conditions. Second, specialty is a growing contributor to the earnings of the Cigna Group. We will deliver 8% to 12% long-term annual earnings growth. And by 2030, specialty will represent more than 40% of the Cigna Group's total earnings. Third, we are the leaders in specialty. We have differentiated assets and capabilities that are very difficult to replicate. And then lastly, we have considerable runway to expand our addressable market, particularly in the medical benefit space. As part of this, we will add about $20 billion in new distribution revenue by 2030. We are the leaders in specialty today. We are well positioned to lead going forward. Thank you all so much.

Please welcome Bryan Holgerson.

Good morning, everyone. I'm Bryan Holgerson, I'm the President of our Cigna Health care business in the U.S., and I also lead our efforts to improve health outcomes for the Cigna Group. I've spent more than 25 years at the company, working with employers and delivery system partners. And what I can tell you is the challenges that they're facing right now in the market around health care has never been more complicated. The health of the population continues to deteriorate, pharma innovation is offering incredible breakthroughs. And at the same time, that combination is creating an affordability challenge that is not only real, but it's growing. And we've seen very clearly that those concentration of costs are increasingly prevalent in individuals with complex conditions. And that's where our health plan model, leveraging the unique assets of our company is built to win.

So today, I'm going to focus on a few key areas that I'll outline here in just a moment. First, it's our differentiation. The combination of our health plans improved affordability position, our strength in our integrated model with particular focus on complex care and our expertise in risk transfer. Second is our market position. Select is our growth engine and how we can extend that growth upmarket. And then third, we are investing in areas of differentiation. And through our execution, what you'll see is we are going to personalize at scale and will strengthen our risk management capabilities. That combination is going to be the fuel for our growth as we go forward.

Now let me back up just a little bit, and I'll start with the foundation for our business. So first, Cigna Health care is approximately 40% of the enterprise earnings, and we serve more than 18 million medical customers. These figures include our international health business, which is growing and comprises about 10% of Cigna Health care. Now today, I'm going to focus on our U.S. employer business, where we serve over 20,000 unique employer relationships, and we serve them across 3 segments: national accounts, Middle Market and Select. And there are several drivers that support our growth across these businesses. First, we have deep employer relationships. And as I mentioned, an improved affordability position. Second, it's our integrated model. We bring together medical, pharmacy and behavioral to create one connected view of the individual. This helps us identify needs earlier. It helps us engage customers more precisely. And ultimately, it helps us deliver better outcomes and lower cost for the employers that we serve. And third, it's our continued growth in Select, where our integrated model, combined with our risk transfer expertise allows us to create funding solutions that are unique to the needs of each individual employer that we serve, which is a big differentiator in the market. And we see opportunity to bring those integrated capabilities further upmarket.

Now that foundation is what's enabled our success over the last 2 years since our last Investor Day. So since our last Investor Day, we've grown our U.S. employer base by 4%. We've gained share in middle market and we've grown in select our targeted growth engine by 12%. That growth has been supported by our improved affordability. As I mentioned, we've improved our unit cost position in 70% of markets nationally. And at the same time, we focused on making care more connected and personalized for the individual that we serve, especially for individuals with complex care needs. So for example, we've expanded our My Personal Champion program. This program is the high-touch support model that supports individuals with complex care needs. Now all of these things combined demonstrates that our value proposition is resonating in the market.

Now backing up from this, the U.S. employer market remains large, and it's growing in line with health care costs. Even as enrollment remains relatively stable, and we see through our value proposition, an opportunity to continue to grow. So I already mentioned our unit cost position. We are in a unit cost competitive approximately 70% of the markets nationally. That's more than double where we were in 2019. Ultimately, what that does is that allows us to compete in more markets where historically we've been underpenetrated. It's a catalyst for growth. Select is our growth engine, and it comprises nearly twice the earnings compared to a share of membership. We have 8% market share, and we've got significant runway for continued growth. Also in middle market where we've got 14% market share, we're growing. In National Accounts, a segment where we've got 10% market share, we see opportunities to bring our capabilities further upmarket.

So in summary, what we have is a scale base a stronger affordability position and multiple clear paths for growth. Now growing is ultimately dependent on the value that we bring to employers and to the customers that we serve. And that starts with how we support individual customers across the health care continuum from the healthy to those who have complex needs. Our Lead-to-One approach is understanding the specifics of each individual person and personalizing care for those individuals so that we can help them improve their outcomes and ultimately lower cost. This is a better way of doing it rather than treating each individual transaction as its own. For people with everyday health needs, capabilities like our AI-powered virtual assistant, helps them more easily understand their care and get answers to questions quickly. And if those needs emerge, we're able to identify opportunities and again, engage them quickly. And for individuals with complex care needs we leverage our clinical support expertise to personalize care and coordinate it.

Now the reason why this approach is really important is because of the challenges that customers, doctors and by extension, employers are facing in the current health care system. So if you only remember one thing about the opportunity that we have and why we're investing where we are, remember this, fragmentation in our system across the health care system represents approximately 1/3 of inefficient spending, 1/3 of efficient spending. This is due to coordination. It's due to administrative complexity. And at the end of the day, it creates low-value care. So a person may see multiple providers. They may receive duplicative tests, and they may have to repeat the same information over and over again. What ends up happening is individuals get lost in the system. Outcomes suffer, employers end up spending more for inefficient care. That challenge is even more pronounced for individuals with complex care. These are the individuals that spend the most time in the system and have the most cost.

The alternative is to bring all of those disconnected pieces and bring them together. This is why our integrated model, which leverages medical, pharmacy and behavioral to create one connected view of the individual, enabling better coordination and better support is so important. And through our Lead-to-One strategy, our goal is to create the next level of personalization to unlock even more value for the people that we serve. Now today, Select is the clearest proof point of how we do this. And not only does it create value for the employers that we serve, it creates business value for us. All of our Select clients have integrated benefits. So medical, pharmacy and behavioral together. And what it does is it creates a compounding advantage. So as we're able to use those benefits in the data and integration that comes from it, we're able to identify and engage customers sooner to impact their health at the end of the day, improve their outcomes and lower cost. We see that happen every single day in an integrated model.

So for example, customers who are integrated, they connect with our clinical support 50% more often than customers who aren't. These same customers also receive behavioral health care 35% more often, and they're using virtual care 63% more often. So for employers, there's direct value, the direct value is lower cost. There's also indirect value. That value is a healthier workforce. There's also aligned incentives in the way that we work with them. through our unique funding solutions, employers share in the upside with us. And this is the value creation that's led to our significant growth since our last Investor Day, 12% growth in Select. And in Select, we generate approximately twice the earnings compared to its share of membership. Now we are going to continue to grow Select. We expect to be at 10% market share by 2030. This is a net new customer growth of nearly 800,000 individuals. And the opportunity to capitalize on our differentiation extends beyond select. So upmarket, we've made really good progress adding pharmacy benefits to our medical relationships.

Our next opportunity is to add medical benefits to where we have pharmacy relationships. This represents almost 10 million pharmacy-only lives across middle market and our national accounts. And this is not reflected in our current growth expectations. So it's additional upside for us. How do we think we can do it? Well, there's 2 things that sets us apart. First, we are going to win on affordability and complex care. As the prevalence of individuals with complex care goes up, and the cost goes up, our integrated model becomes even more important for the clients that we serve, leveraging our pharmacy, specialty and behavioral assets combined into one integrated view of a customer, that gives us a competitive advantage. And second is innovation in this area. You will see we are going to invest in new services and capabilities that are going to improve the customer experience and expand our clinical impact to create even more value.

So here, the opportunity is really straightforward. We have strong relationships today. We're going to leverage our differentiated capabilities and we're going to invest more here to help individuals with complex needs. Now I'm going to go a little bit deeper into the capabilities around this behind our differentiation. So this is an important slide. It's important because it outlines the interconnected capabilities that we're investing in as we go forward. First, we are going to strengthen our integrated data foundation to build an even more connected view of the patients that we serve. Second, personalization at scale through a new customer and clinical support model that we call Health Sense, which is powered by our health intelligence engine. And then third, we are going to build on our leadership in risk transfer expertise. We are going to do this by using our personalized data and capabilities to not only improve outcomes and affordability but also leverage it to strengthen our underwriting and our risk management performance.

So while each of these capabilities is important on its own, it's really the combination that's going to create the fuel for growth as we go forward. So next what I'm going to do is I'm going to break down each one of these, so you guys can get more of a picture of each of the pieces. I'm going to start with integrated data. So the value of our integrated model shows up in the numbers. Across our book integrated customers save significantly more dollars than our nonintegrated customers. And that value rises with complexity. So for an individual with cardio, diabetes, obesity, it's $2,000 per member per year. For the average specialty condition, it's $8,000. And for a cancer patient, it's $28,000 per member per year. And that's because there's no standard journey for an individual with a complex condition. Every individual we serve with a complex condition and even those that have the same diagnosis can require different care treatments, different settings and they may need different support.

The best care plan is one that's individualized for the person. Our integrated data gives us a connected view across the health care journey. And combined with our capabilities in pharmacy benefit services and specialty and behavioral, we can deliver a more personalized, coordinated care experience for an individual. So let me give you a couple of examples. For a patient with cancer, we are able to leverage our site of care capabilities to make sure that high-cost infused drugs are not only delivered clinically appropriately, but in the best setting for cost efficiency, and we can connect them to our therapeutic resource centers that Matt described earlier or for a patient with rheumatoid arthritis, we can help improve affordability by leveraging our biosimilar capabilities through Quallent, and similarly, we can ensure that these individuals are connected to our inflammatory therapeutic resource center. So because we see more of the patient's journey, we can make the right connections to make sure they get the best outcomes at the lowest cost.

Now the next opportunity that we have is to use these insights earlier and even more precisely. So this is why we're investing even more in personalization at scale. As I mentioned earlier, fragmentation is a huge barrier. It's driving much of the waste that's in our system today. And we see this as a huge opportunity. It's an opportunity for us to transform the market expectation of our impact. And through Lead to One, we are building on our integrated capabilities. We're using AI to personalize support at scale. And this is why we're introducing HealthSense. HealthSense is our next-generation customer and clinical support model. It is going to deliver more personalized, proactive and continuous support across the individual's health care journey, powered by our health intelligence engine, and embedded across our Cigna Health care experience. It combines data, AI and personalized clinical support to anticipate needs, guide actions and connected individual to the right clinical support at right time. We expect the impact of this work to reduce health care inefficiencies by 10% by 2030. Katya and Dr. Flaster are going to go deeper on these capabilities in a few months.

Now when we combine this work with our risk transfer capabilities, it creates even more value for the employers that we serve and by extension, creates more value for us. Earlier identification and better engagement leads to better outcomes and lower cost. It helps us better predict and manage risk also. So the question is, why does this matter? What matters because we are the industry leaders in stop-loss. Our expertise has allowed us to build the industry's best risk management engine. These capabilities support a broad range of funding solutions from our fully insured to self-insured and flexible arrangements in between. That flexibility is particularly important in our growth engine, Select, where 68% of our clients are self-funded and the markets at 3%. For clients who choose self-funded or flexible arrangements, we help them manage the risk, and we have aligned incentives. So when we create value for them, they have a lower cost and we are able to participate directly in the value that we create. So our risk transfer expertise is not only a competitive advantage for us, but we're also using it to strengthen position through advancements in predictive analytics. We do this by drawing on hundreds of millions of claims and our clinical interventions that we have to create a more connected and fuller picture of an individual. This is what enables the identification in the intervention that I spoke about. It is also what is allowing us to sharpen our risk management and our underwriting skills.

Now at the end of the day, execution is what's critical to us taking advantage of the opportunities that lie in front of us. So there's 3 particular areas of focus around execution. The first is expanding our addressable market. By expanding our addressable market, this gives us further runway for growth. We will further improve our unit cost position by another 10% by 2030. Second is innovation. We are investing in new solutions to bring to market that will personalize individuals are at scale and help us make that impact. Again, Katya and Dr. Flaster are going to go deeper on these capabilities in just a little bit. And then third, we are leveraging technology to improve our risk transfer capabilities. Not only will that fuel the identification, the engagement and the clinical impact, as I mentioned, we're using it to sharpen our underwriting and our risk transfer skills.

So let me leave you with what matters most, a few things. First, the combination of our improved affordability position, our integrated model, in our risk transfer capabilities create a competitive advantage for us to trade off. Second, the employer relationships that we have and specifically the momentum in Select will help propel us, and we think there's opportunity to continue to do that upmarket. And third, the execution discipline that we'll bring, particularly in areas of differentiation is going to matter. This will help us improve our addressable market. It's going to help us strengthen our risk management capabilities and it's going to help us personalize at scale. So this is why we're confident in the commitments that we've laid out. one, delivering earnings growth of 6% to 9%; two, expanding our select market share to 10% by 2030; and third, reducing inefficient care through a focus on the complex by 10% by 2030. Thank you all.

Please welcome Adam Kautzner.

Good morning, everyone. My name is Adam Kautzner. I am President of Evernorth Care Management and Express Scripts. I'm also Executive Vice President of Customer personalization for the Cigna Group. And I'm excited that all of you are here with us today as we talk about our pharmacy benefit services business and where we are currently today and where we're going for the future. I'm going to cover 3 main components today throughout the presentation. One is how we remain an essential partner around managing the growth of drug spend. Two, we continue to innovate and lead the industry as evidenced by our signature pharmacy benefit services model that I'll go into deep later on. And lastly, how we will continue to deliver sustainable and durable earnings that are predictable for the long term.

Today, we have a mature and stable pharmacy benefit services business. We have $140 billion annually, of which $2.6 billion is earned income before taxes. We service 117 million Americans, about 1/3 of the entire country's population. We'll process over 2 billion prescriptions this year, and we manage a pharmacy network of over 65,000 pharmacies across the country. It's this size and scale that we have that allows us to be able to deliver an unmatched cost of goods, it also allows us to be able to continue to innovate around market-leading solutions around complex care. And lastly, it provides us with the ability to go deep with our clients from a clinical and care perspective to deliver on safety and efficacy for them. Now it's been a couple of years since we've all been together. And during that time, we've been very busy.

We've delivered on strong new sales growth, which has manifested into a 30% plus revenue CAGR during the period. We've also continued to go deeper with our clients. and improve those relationships as evidenced by our client retention levels of 95% or higher. We've continued to innovate in the spaces around disease-specific therapies for patients requiring those complex care needs. GLP-1s is one great example, where we've had the broadest suite of solutions in the market, and we've been able to continue to move that market as it has evolved over that time period. And then lastly, our new rebate-free signature model, which is revolutionizing the industry, delivering change that has been not seen in decades within the space.

Pharmacy Benefit Services today is a $500 billion business, of which 70% is for patients that have complex conditions. Those patients require specialized care. This is also where pharmaceutical manufacturers are continuing to focus. 75% of their pipeline spend today is for those patients that are requiring those complex conditions. What that means is that over time, we're going to continue to spend more and more on fewer and fewer patients. This is where our vision around Lead to One continues to come in. The development of our signature model as well as us continuing to develop disease-specific solutions that provide best-in-class outcomes for our patients and for our investments within the technology space that you'll hear more about later today. One of those is our new leading industry component around our platform, which will set new industry standards for flexibility, speed and quality. Those areas of focus are continuing to be extremely important as you look at the continued growth within the pharmacy space.

Just a decade ago, pharmacy only accounted for about 20% of of total health care expenditures. Today, it's 30%. And in another decade, we project it to be over 40%. Much of that is because of the specialty space. and that continued focus in that area. Specialty only accounted for about 12% of total health care expenditures a decade ago. Today, it's about 20%. We project it to be about 30% in another decade. This is requiring real focus, where a pharmacy benefit services company can't just adjudicate claims. They have to have a much deeper understanding of the clients' needs of what's happening in the market and be a strategic partner for clients and patients alike. That's where we continue to step in, and we're able to continue to successfully bend that cost curve. It's also an area that we have quite a bit of experience in, because if you go back a couple of decades ago, generic drugs only accounted for about 40% to 50% of all prescriptions.

We went to work educating providers, clients, patients on the access and affordability benefits around generic prescriptions. What that has allowed us to be able to do is use that type of playbook here today, generics account for 9 out of every 10 prescriptions and use it within the specialty space around biosimilars. Biosimilars provide an opportunity of 60% or greater savings over and originate biologic, and we're utilizing that type of success with the biosimilar medications, HUMIRA, it was the largest drug in the world. We've been able through our work to ensure that 85% of our eligible patients are trying that biosimilar product. STELARA, another blockbuster medication. About 75% of patients are trying that biosimilar product. It's that type of success that we're continuing to utilize as we work through a highly evolving market. Because for the first time in decades, we're actually seeing a decline in gross rebates. Whether that's most favored nation inflation reduction act effects or biosimilars, we're seeing gross rebates come down. That's leading to more unpredictability for our clients because they retain all or nearly all of those rebates today, and they're looking for something that works and provides them with better predictability into the long term.

In fact, as we polled our clients, many of them are seeking new innovative components for the future. And our new rebate free model looks to deliver on that for them, where nearly 90% of our clients are seeking better transparency more predictability and being able to address the emerging concerns around fiduciary responsibilities. Signature addresses those concerns. The same thing for patients. Nearly 80% of our patients that are pulled have a pretty reasonable ask. We want to know what the cost of that drug is well before we go to the pharmacy counter. This is something we're able to deliver with our new model and our price assure functionality, where we're delivering on new upfront discounts that are negotiated on behalf of our patients where they can see real meaningful savings at the pharmacy counter.

But before I go deep on Signature, let me talk about 3 areas where we continue to excel in the market. Our product solution suite our ability to bend the cost curve from an affordability perspective and our safety, clinical and quality components. On our product and solution set, we have the broadest breadth and depth of solutions in the market. We're able to understand what our specific clients needs are for their unique patient populations. By doing so, we're able to curate solutions that provide a customized effect for exactly what they're looking for within that solution set. From an affordability perspective, we continue to apply tried and drew measures from a formulary development perspective that can bend that cost curve while maintaining high levels of member satisfaction. And lastly, on the clinical quality and safety components, on every single prescription, as I mentioned, we're going to do over 2 billion prescriptions this year. We perform 18,000 safety, quality and benefit checks nearly instantaneously to ensure that every single patient is receiving the right drug in right amount where and when they need us. This is what our clients and patients count on, and we deliver it millions of times every single day.

How that comes to life in terms of specific client examples? This is a large employer that recently became part of our portfolio. This was an employer that business was doing really well. They had a relatively unmanaged plan, as you can see by the level of spend, about $360 per member per month. And they knew that, that was unsustainable, and they were looking for real solutions to bring that cost down. But at the same time, they needed to better understand what it would do from a member affordability perspective and member satisfaction. We spent time with them, understanding their specific needs for their populations. And we deploy a multitude of solutions. So not one size fits all. We went deep, we understood what are all the different components that they needed, and we deployed those types of solutions. We cut their costs in about half, and we were able to maintain true high levels of member satisfaction. It's that type of approach that's a personalized component where Evernorth continues to excel and deliver on the market compared to where others are.

It's also that type of better understanding and innovative approach that we're applying to the market with our new signature pharmacy benefit services. We launched Signature back in October of last year, but there was a lot of work, a year plus in advance because we knew, given the unpredictability and change that was happening in the market, there had to be a better way. We start with the consumer, understanding and addressing their pain points from an affordability perspective and then worked back to solve the rest of stakeholder needs across the market. So we launched Signature in October of last year. Subsequently, we proactively engaged with the Federal Trade Commission and reach a successful settlement.

And then earlier this year, Congress passed the Consolidated Appropriations Act. It's the most far-reaching industry change that we've seen in decades. Those 2 items create a federal clearing event for us across that landscape. We're now moving into an execution phase as we've been educating the market, we're going to go live for Cigna Healthcare's fully insured book next year with Signature, and then the rest of the commercial market has the opportunity to then enroll in 2028. Now keep in mind, during that time as well with the CAA going into effect, the entire market is going to have to make changes around how they procure pharmacy benefits. That provides us a real opportunity given the evolving components that are happening within the market and our ability to affect that change.

Signature has 4 unique components. One is specifically for the consumer. It's real meaningful discounts in a transparent way at the pharmacy counter that we negotiate upfront. They're not retroactive, they're not retrospective or estimated. They're real discounts as we continue to redefine how we negotiate within the supply chain with manufacturers. Second, transparency. Our clients demand additional transparency, Signature delivers on unprecedented additional transparency, so they can track where every dollar goes within their pharmacy benefit. Third, how our fees are structured. So no longer will our fees be tied to the cost of a drug. Instead, it will be a simple, flat administrative fee tied to the value that we provide to our clients. What that delivers? Sustainable, durable earnings in a predictable fashion for the long term.

If you dig a little deeper in terms of what that means from a patient perspective, patients today that are taking high-cost branded drugs, we'll see on average savings at the pharmacy counter, if they're in a deductible phase or if they're in a high coinsurance environment, savings of about 30%. Upfront, predictable, meaningful savings. And for our clients, since we're able to continue to negotiate through redefining the supply chain, with minimal to no plan design changes, we can deliver cost neutrality to our clients. This provides them with the high level of transparency, better member satisfaction and experience and delivering on that cost neutrality component. That's what makes our model unique and why we'll be successful for the long term. And in fact, Milliman just released yesterday an independent study that confirms this component around the cost neutrality components and the benefits that, that provides long term.

Now, we've covered quite a bit of information already today. But what I want to be able to convey is how are components from an earnings perspective are also going to change. So let's go back to that client example that we looked at earlier, the large national employer. Today, our earnings are composed of about 54% in a simple administrative fee and about 46% of our earnings from that client are from small components that we retain from a supply chain perspective. Tomorrow, within the Signature model, 100% of our fee earnings is going to be from a flat administrative fee within the additional opportunity to sell in the product and solution suite that we have around new disease-specific solutions and some opportunities around shared savings.

But what's important is in the middle. So our earnings today on this client, they're a little bit higher than what our average target earnings are about 4% -- at 4.5%. But it's 4.5% today. It will be 4.5% tomorrow within the new Signature model. So transitioning to a more predictable and durable type of solution, but it provides us with that predictability through a new simple administrative fee. We've covered a lot of ground already today. And what I've been able to talk through with you all is the benefits that our new model provides in reshaping this industry. But you're not going to just have to take my word for it today. We are lucky enough today to have 2 of our nation's industry experts around pharmacy consultant benefits, and they're going to join us up here on stage.

So please welcome A.J. and Alicia to the stage.

All right. So Alysha Fluno is national pharmacy practice leader at Marsh. Alysha spends her days, consulting with employers all different sizes across the market and educating them about assessing different types of pharmacy benefits and this highly evolving market. And AJ Ally is Principal and National Pharmacy Consultant at Milliman, and AJ works across many different partners within the pharmacy landscape and employers, assessing the market this highly evolving market and how to ensure that employers can get the most out of their pharmacy benefits.

So with that, why don't we jump right in. Alysha, we'll start with you. What is the biggest pharmacy benefit challenge that you're seeing with your clients today and challenges that they're starting to have that they're trying to solve for today and what if anything has changed over the last few years?

Sure. Well, Adam, thank you very much for inviting us to be on stage. This is an honor and a privilege. But regarding employer clients, those are the clients that Marsh serves from a pharmacy perspective, there's 3 main things that are top of mind for employers today. The first is affordability. They have seen over the last decade plus probably double-digit trends in pharmacy. The last couple of years, we have now added on some significant trend that's happening on the medical side as well. So the affordability component is becoming real for our employer clients. and they're starting to question the sustainability of them being able to afford and continue to afford high-quality benefits for their members going forward. So affordability is in the forefront of employers' mines.

The next is transparency. You hit a little bit on this, but the definition of transparency changes throughout the industry, but I really think in today's world and kind of moving forward, transparency is basically table stakes at this point. Employers want to know what they're spending and where their money is going on the drugs and the benefits that they are spending because they want that revenue transparency. In addition, they also want better access to their own data, reporting those types of things. And the third component that's top of mind really is just fiduciary responsibility. You all have seen it before. Nobody wants to be that next headline in the newspaper from a fiduciary perspective. So employers are very keen on making sure that every selection that they make follows their fiduciary duties to their employees. So while they have all of these components that they are managing on a day in and day out basis, employers still need simplicity. Our pharmacy, our health care system is very complex. They're really looking for simplicity in the benefit and then predictability in the costs.

That's very insightful. Appreciate that. AJ, I talked to this group today about some of the additional clarity that we have around the federal landscape today, our FTC settlements into others who had FTC settlements, the passage of the CAA and it going into effect in a couple of years in that effect. And then the emerging change now of more and more focus around fiduciary responsibilities. And how are employees thinking about the fiduciary component? And how is that influencing their decision-making as they assess these new aligned models?

Thank you, Adam, and good morning, everyone. I think as you think about the pharmacy supply chain right now, it's very fragmented, and it has created a lot of point solutions, whether it's direct to consumer or direct to employer, you name it. And why is that? So transparency, I think, is a table stake today. And what is happening with all the shift in regs, there is a shift in responsibility to the Arista plan sponsors, the employers. So today, for example, and some of you in this room can relate to it. If you try to use your pharmacy benefit, a large percent of the time, patients have to navigate to figure out where to get the lowest cost option and sometimes it's not in their pharmacy benefit. They have to go to some other point solution like GoodRx, Cuban, et cetera. tomorrow with some of the changes that are happening, the employer is going to have more of their share responsibility to take on this particular responsibility where I think going forward, if a PBM can offer an integrated benefit where the patient doesn't have to go navigate for drugs that are covered or uncovered, but it's available within the benefit regardless of whether it's covered or not and get the lowest cost option, that's going to be a differentiated model.

Second, I think, is the aligned incentives. I like that one slide you shared where you said for every $1 in margin you create $11 of value to the plan sponsor. We have never seen that before. I have never seen that in my career 25 years. I think that's going to be more something that plan sponsor going to demand and be able to prove and having aligned incentives for both managing trend, controlling spend is going to be a big differentiator going forward.

Thank you. Alysha, as we talk more about the new transparent models, our signature model that we recently released. What's the general interest level from a client perspective in these new models?

I'm going to say clients are curious. They are interested in exploring new and different ways. There's been a lot of involvement over the last couple of years with some of the smaller, newer niche PBMs coming to market and bringing their PMPM models or trend guarantee models forward. and we've seen some movement in the market. But this is a pivotal time because now we have what we consider as being a large PBM kind of leaning into that type of a model. You're going to be able to do things that some of these smaller different PBMs aren't able to do because of the assets within the enterprise that you can bring forward you bring a lot of scale and market presence that we have not seen before. So I say employers are curious, I'm going to also expand it to say we are beyond that first mover phase. We're really in the fast followers now. And I think bringing market -- bringing your new signature model to market. is perfect timing to kind of catch some of that win that's been happening.

Right. And I think that level of curiosity is where employers, clients of all different labor unions, health plans, there are different levels of that change curve. And so as the CAA goes into effect in a couple of years, how that change happens and where we have to meet those clients is going to be important. So for us, even though signature is our standard model, we're going to remain flexible in the market and have rebate models as well that are CAA compliant to because we'll have to meet them in different areas as we transition over those next few years.

Yes. And as AJ said just a minute ago, employers like the fact that the incentives of the PBM and the employer are aligned, right, in a PMPM model. it's in your best interest to drive to lowest net cost and to get members on the right care to eliminate some of the waste that's happening in the system today. So employers are excited about that.

And AJ, to Alysha's point on different models now that are emerging, how would you compare and contrast to the new models that are out in the market?

That's a loaded question. So the reality, though, the PBM models, the various transparency models have been evolving in the last 10 years. But I think it's important to recognize what's new and what's not new. So models like pass-through pricing, cost plus, acquisition cost plus, point-of-sale rebates, those are not new. PMPM guarantees where the PBM put a guarantee on the cap of spend for a plan sponsor, that's also not new. But I have to admit the rebate free model where the manufacturer passes the value at the point of sale of the pharmacy counter, that is new. In fact, you referenced the Milliman study, I was part of that. It was an independent study that we did we compared point-of-sale rebates to the rebate free model because there's a confusion around the 2 in the market. And what we found was that the plan sponsor actually benefit from the time value of money. And all of you in this room are expert in time value of money over me, myself.

And what was interesting was that this time value of money, the average plan sponsored for let for example, a high health plan, the time value of money was about $1.25 per member per month. That's real dollars. And this assumes all that remain the same. Drug spend remain the same. Plan design remain the same, pricing will remain the same. This is true the time value of money just by floating that cash float upfront to create the value for both the plan sponsor and the member. And it was assuming a 7.5% interest rate for those who are interested in how we came up with that and welcome to read the report. So the plan sponsor basically are benefiting from this cash flow to where -- because they're paying less, if you think about how benefits are paid today. They're paying less earlier in the financial cycle and they benefit both the member and the patient, which is the patient and the plan sponsor. So I think this was a big aha for me because we have never as consultants measured time value of money in anything when we evaluate pharmacy benefit.

We talk about it.

We talk about it, but we never measured it. So -- but yes, I think the market is moving where it will be interesting to see how these various transparency models, including the new one that Evernorth is launching, how it will impact patients and plan sponsor going forward? And how will change the way benefits are going to be evaluated by consultants and decisions are going to be made in terms of how business are placed because there will have to be a lot of changes in that whole process.

Right. And in your study, the although there is cost neutrality, then you pick up the time value money piece, which I think you quantified too, which is meaningful for employers. Alysha...

Do you mind if I add to that a little bit, though, I think there's more than just the rebate free that is unique in the model that you are bringing forward to the market, so as I said, we've seen PMPMs before, but for some of these niche PBMs that are in the market. What's different is the acquisition cost basis that you're bringing forward at the 3 different dispensing channels, if you will, right, mail order and specialty assets that your enterprise owns. That is something that other PBMs in the market outside of really the big 3 can't really bring to market because they don't own those same assets. So you're going to have an advantage, I think, over some of those opportunities and other PBMs in the market. because you can bring that scale in a different way. I also think it's unique the way that you're recontracting with retail pharmacies as well to provide better reimbursement for when members are at the pharmacy counter and picking up their medications, I think that, that is a differentiator as well in the marketplace.

Great. And then we're transitioning to from rebate -- from rebate economics into transparent administrative fees? And how are employers really should reassessing what that will mean in terms of comparing and contrasting the different payment models?

I think we're all actually adjusting to this, not just the employers. So I think it's fair to say that the economics for the business are changing. They're fundamentally changing from multiple different revenue streams, many of them hidden in the PBM industry, where we haven't seen those revenue streams before. The revenue is changing for that to a more transparent upfront no undisclosed revenue model. In that type of a scenario, we need to be open to the fact that administrative fees are the only area where a PBM is actually making revenue. So those administrative fees are going to feel very different. You just heard Matt in his presentation earlier, talking about the clean sterile rooms and they're adding a fifth one and all of that and the cost that goes into just even being able to maintain and deliver medications to patients. There's a cost to that business, and you guys have to run that business.

And now instead of that being hidden behind claims and being afforded through different spread pricing models that is now being pulled front in an admin fee which will be fully disclosed. So we need to be comfortable with the fact that these admin fees are going to be much higher than what we have seen in the market. But as we're doing our work as consultants are doing their work and kind of looking at total cost to administer a benefit, those admin fees will be neutralized by the offset of the good things that you're doing on a drug cost perspective and the ability to bring rebates forward and provide more affordability that way. So I'm excited for some of this to come forward. But yes, it is a shift in mentality on the admin fees.

Thank you. All right. Final question, crystal ball time. Five years from now, as we look at the different models that are out there, what are some characteristics that you think the winning pharmacy benefit models will have when we get out to 2031. AJ, will start with you.

Okay. If I had a big 3 characteristics. The first one would be around operational efficiency. So scale and size would matter, both in terms of delivering value as well as the administrative fee that comes with that. So operational efficiency and then, of course, the application of AI to reduce the cost to administer the benefit, very important. The second, I think, is the most important one. is the ability to manage spend and trend across the pharmacy and medical benefit, especially for high-cost specialty drugs. That is going to be a key differentiator because you saw -- you said it on your slide today, pharmacy spend is around 30% of the health care dollar across pharmacy and medical benefit is going to go to north of 40% within peers. So the ability to manage drug spend, high-cost truck spend across both pharmacy and medical is going to be super important. So trend management and clinical management are going to be critical characteristic.

And the last one, I would say, is the ability for the PBM to create value. And what does that mean? So depending upon who the plan sponsor is, whether it's a health plan or an employer value can mean financial value. It could mean member experience value or clinical value, respectively. So I think the PBM who can create value based on the stakeholder they're serving depends on who that client is, is going to be critical for success.

Alysha?

And I would say I agree with that wholeheartedly. AJ. And I would just add kind of what's old is new again, right? So 10 years ago, we were all worried about the cost and trends that hepatitis C medications we're bringing into the market and how could we sustain those costs? We got over it. Today, I can't believe we have had a pharmacy conversation and haven't said this yet, but right today, employers are really struggling with the cost around GLP-1 medications and what that is doing to plan spend as well. We're going to get through that as well. When I look forward 5 years from now, what's in the pipeline, what's coming, it's these multimillion dollar gene and cellular therapy drugs that right now, we kind of talk about them as a lightning strike and don't worry that loss will take care of it. It's not going to be that way in 5 years. These are going to be chronic maintenance medications that patients might be on longer term or expensive, even more expensive, right, multimillion dollar therapies that hopefully are curative for patients. So we need to lean into, as AJ said, managing across the benefits, pharmacy and medical, but really starting to look forward to how do we do benefits differently going forward with an eye on those that are really high cost.

I want to thank both of you again for being here today and sharing your insights. I know this group, I'm sure has found this. So really, really helpful as we embark on an exciting time in the pharmacy benefit space. So thank you.

Yes.

Thank you for inviting us. Thank you. Appreciate it.

All right. So in closing today, around our pharmacy benefit services business. We at Express Scripts continue to be an essential partner in managing the growth of drug spend for our clients in this highly evolving market. This is an area where though Evernorth, we continue to excel and lean in with our clients. Second, we are leading the market from an innovation perspective. You just heard that from 2 of our leading experts in the country as well. And through our Signature pharmacy benefit services, we will continue to set new industry standards around transparency, accessibility and customer affordability. What that will deliver is durable and sustainable earnings in a predictable way for the long term. And it's based off of those statements that we can make 3 commitments to you here today. One, we will deliver up to 4% earnings growth year-over-year through 2030. That earnings growth will ramp over time. We're in a highly dynamic market today as the rebate market is transitioning. And as we ramp through 2030, up to that 4% from an earnings perspective.

Second, we will continue to have high client retention of 95% or higher while delivering on strong profitable new sales growth. And three, by the end of 2028, we will have enrolled at least 50% of our members into Signature models. I want to thank you for your time today.

We're going to pause for a short break. Our next session will begin in 15 minutes.

[Break]

Please welcome Katya Andersen.

Thank you, and welcome back. I'm Katya Andresen, and I'm the Chief Data Digital and AI Officer at the Cigna Group. I've spent my career working at the intersection of technology and experience in health care but also in other industries, including consumer banking. And one thing I have learned is that powerful technology eventually ends up in the hands of everyone. So the real question is not what are we doing with technology? It's how are we leveraging technology and now including AI in ways that create measurable value. So what you're going to hear from me today is an outcome story more than an AI story. .

Throughout the morning, you've heard how we're making health care more affordable and personalized especially for those with complex needs. My role today is to explain how data and AI support those outcomes. And we'll cover 3 things today. First, how we're already creating measurable value now across our businesses and for our customers. Second, I'll talk about how our health intelligence engine accelerates that value in a way that compounds. And third, I'll talk about where we're focused because we have durable advantage and where we partner to move faster or more efficiently. So let's start with our approach to creating value now. We don't start with a question of what to do with AI. We always start with a question, what meaningful problem in our businesses or in health care at large, can be solved in ways it couldn't be solved before because of advances in AI. And we reimagine whole domains of our work through that perspective.

We measure impact and we only scale what works. And that disciplined approach has yielded significant value for both efficiency and experience. All the while every step of the way we are reusing capabilities and we're amassing a body of intelligence that's growing larger. And that means each subsequent solution is cheaper, faster, more precise and more effective. I want to show you some examples of that. In Cigna Healthcare, we're using AI to answer customer questions quickly in a personalized way in digital channels. This means people don't have to pick up the phone and call us. That's resulted in a 20% decrease in phone calls per customer over the last couple of years.

In MD Live, which is Evernorth virtual care provider. We're using AI for clinical documentation. That's taken the time that clinicians have to spend on not taking down by up to 90%. And in pharmacy benefit services, we're using AI in our specialty benefit review process, taking that down from 15 minutes to 21 seconds, which is 43x faster. Now we're turning to the great opportunity Brian talked about in complex care. And I want to make that concrete. So let's think about someone with complex needs. They have multiple conditions, multiple therapies. They have multiple providers and benefits, and that creates a very scattered set of snapshots, a prescription over here, a clinical event over there, a claim somewhere else.

So how do we take that scattered picture and turn it into a picture that allows us to create meaningful outcomes for those people. Our answer is our health intelligence engine. And I want to describe how that works. There are sort of 3 groups of capabilities that are part of the engine. The first thing is what we know. So think of this as capabilities around our integrated data across medical, pharmacy, specialty behavioral health. Then there's what we can predict, that is our proprietary models as well as our ability to identify the right personalized recommendation, leveraging our clinical expertise which you'll be hearing more about from Dr. Flaster. And third, there's leveraging what we know and what we predict to find out the right best thing for what we should do and then taking that action.

So what we know, what we predict, what we do, one more point I want to make here, which is what we learn. Because this is happening across millions and millions of customer touch points. And that means that every time we learn something, we know more and that makes our next solution more effective and powerful. We have been building these capabilities for years. At the Cigna Group across the enterprise, we have over 700 patents. And my team filed a machine learning patent back in 2014, long before we were all talking about AI all the time. So don't think of this as a new platform. It's not. What is new is what recent advances in AI, including Agentic capabilities, due for this model. It's supercharges it. We know far more. We can predict with greater precision at greater scale, and we can do more. And we can learn faster than ever before. So here's what that means for our results. especially for those with complex needs.

So first example. In Cigna Healthcare, we are able to significantly reduce inpatient and ER department visits that are avoidable. In specialty pharmacy, as you heard from Matt earlier, time to therapy is doubled, twice as fast. For a complex patient getting on care faster means everything. In Cigna Healthcare, our virtual agents are solving over 70% of customer needs in digital channels and very exciting. Our care managers now can act with the precision and personalization that helps engaged customers have $22,000 a year, $2,000 a year less in medical costs. So all of these are very powerful on their own as this engine becomes supercharged. What's equally powerful, I want to emphasize again, is the learning loop that this creates.

And value is compounding in 3 ways for us. First, in business performance; second, value is compounding in our delivery economics with every new solution. And third, growing commercial value, both for our existing offerings and the new offerings that are now possible. This is the most important slide. You'll see from me I want to make another really important point about it. And that's that the more complex, the health care journey, the more valuable this thesis. Others may have AI, they don't have our context, and they don't have years of learning what works for whom under what circumstances. And moreover, having done all of that with built-in guardrails around models and agents and human accountability.

We also know in the space, it's important to move fast. So we don't believe in building every capability ourselves. We invest where the advantages must be ours. So think of that as my list, what we know, what we predict, what we do, what we learn. We partner where technology companies that have specialized expertise can help us move much faster. And a great example of that is our partnership with Sierra AI Sierra is a leader in conversational AI and genic servicing. And they have helped us move very swiftly in our voice channels, such that we can answer any customer inquiry in a natural conversation in the most personalized way based on our health intelligence that has ever been possible before. And today, we've invited the Co-Founder and CEO of Sierra to be with us today. Bret Taylor. A word about Bret. He's been behind some of the biggest technology innovations I'm sure you're familiar with, including creating Google Maps. He was CTO of Facebook. And Co-CEO of Salesforce; and now Chairman of the Board of OpenAI. I'm delighted to welcome Bret to the stage.

Bret, thank you so much for being with us today.

Thank you for having me, and thank you for our partnership.

Yes. I'm going to jump right in about our partnership. So I wondered if we could start out talking a little bit about you work across a lot of industries. Health care is very special. What are you learning about health care? And what have you learned from the partnership that we have?

Well, I think health care is probably, I think, has the highest potential for a positive impact with this current generation of AI. I'm -- you've probably forgotten more about health care than I ever know. But we spend about 18% of our GDP on health care in this country. It's one of the few industries that has gotten less productive over the past decade. And so whether if you look at the shortage of pharmacists to registered nurses to doctors to the administrative costs, I think that there are so many applications for this technology that can go directly to the benefit of members. And I think that's what I've always drawn me to Cigna you're focused on member first.

I think the thing that's been most exciting in our partnership has been the application of voice. So if you think about what it means to create digital experiences in the dark ages of 3 years ago, that meant a website or a mobile app with voice AI, we've essentially digitized the last remaining analog channel, which is the telephone. And the telephone is incredibly important in the health care industry, whether it's outbound callings partners or inbound calling from members. It's remarkable how well this technology can work. You've mentioned some of our partnership, the Accredo AI agent is autonomously handling over 40% of calls. These are basically members is better, faster and cheaper. Right now, it's essentially the benefits are to everybody, the member to you, to the bottom line. So I think sort of thinking it was Maslow's hire give needs, first find shelter, like let's take the billions of phone calls in the health care industry that could be automated and apply it there. And then I know a lot of our conversation will go to sort of the longer horizon of this technology where we can really help to drive outcomes for Cigna members, particularly for these complex cases, which I think are people who are most vulnerable and most need the can most benefit from this technology.

That's great. I share your enthusiasm for voice, obviously. I think it's important incredibly important in health care. It is still early innings for waste in the AI space. So I think it would be really interesting to hear your perspective on where it's going and then what that means for advantages for our partner going -- our partnership in the future.

Well, I think it was really captured by the slide you just presented actually, but I'll sort of take a step back. So as AI models become more capable, we've gone from sort of reasoning about sort of a single decision to thinking about how do you actually orchestrate a longer horizon engagement. And if you think about a Cigna number with complex care needs, it's a perfect example of this. And it goes from how you digitize a phone call to can you actually orchestrate a member journey to drug towards an outcome, I think things like prescription drug adherence or almost creating a digital health advocate for each member. .

If you think about the cost of sort of the high end of the health care market, where you can actually have concierge, doctors and health advocates with AI, we can digitize that. And we can provide that exclusive service in a much broader way and actually drive outcomes that just weren't possible before. And in particular, if you think about some of the complex care scenarios you're focused on, it's something that is only possible with AI to do in a cost-effective way. And so I think about outbound engagements, AI not just reaching out to you, but deciding to reach out to where everyone's journey is different. I think about automating sort of some of the relationships with partners, if you think about the complex supply chain of health care.

And what I loved about the way you presented it, we have a saying at Cira, which is rent the intelligence, on the context. And I think over time, AI will be broadly available in the health care industry, you can't really differentiate on intelligence by itself. But what you can is have more context about your members and use that to make more intelligent decisions about how to engage with them and drive those outcomes. And I think both because of your portfolio of companies and services and how far ahead you are on AI, I think you're going to start compounding some of that context advantage over time. And for selfishly as an AI person, I think we'll be able to see the impact of the technology faster with you than almost anyone else, which is such a privilege.

For us, too. And I'd like to follow up on something you just said. So I agree, we're in a stage now where we can do inbound. We're doing outbound as well in certain parts of our business. But what really matters is that connected journey. And we believe that's the place we really want to be ahead of the game, as you said. And can you talk a little bit about Sierra's plans around Agentic harnesses or the ability to connect these journeys no matter what modality someone is in or wherever they are in their journey?

Yes. The spirit of sort of renting intelligence in the context is how important the context is. To some degree, that universal profile of me and who I am is the most valuable thing. And no matter how advanced DPT 28 is, it won't know what you know about me as a member of Cigna. And that context about me is actually the most important thing to drive value from this what will become super intelligence may already be super intelligence in the future. And what's interesting about essentially making AI agents, our digital front door for the connected member journey is that every interaction I have with AI adds to that context. Because if you think about it, how many conversations over the phone like what do you log in the computer system?

Well, now if you're having a conversation with an agent, whether it's over the phone or a digital voice experience or a digital tad experience, all of those memories are actually a part of my unified profile. And essentially, the more you lean into AI as your digital front door, the deeper your context moat becomes. And -- but more importantly, for Cigna member, the more intelligence you'll have about how to drive me towards that outcome to help me in particular I'm way out of my depth here, but for some of the sort of complex therapies, just even the active taking them correctly is going to really drive outcomes and to actually have as much context as possible to drive those outcomes, I think, is an incredible opportunity. And so I've obviously sort of biased in this assessment, but I think the more companies lean into AI as their digital front door, the more their AI will actually perform better. And I think it's also why I think you all leaning in to move more quickly than many of your peers are so important because you're getting those lessons faster than anyone else.

Yes. Thank you for really underlying a compounding value that we're seeing here because this engine and the interactions with the agents create more and more data, and that makes the whole thing more and more valuable and great for outcomes. Okay, speed round, quick question for you. skeptical investor might say everyone has access to AI, know really where is the sustainable advantage. And you've talked about context, but can you put a finer point on that?

Yes. So if you think about -- I'll just give you an anecdote. I just added my 16-year-old daughter to our car insurance, which cost me an army in the lake. In that conversation, I mentioned jokingly that I have a 15-year-old son, and I'll be calling them next year, which is true. And because I'm in my line of work, I wondered, I bet that's not being recorded anywhere. And I just gave them an opportunity to reengage me and upsell me, and I give them the date to reach out to me. I think that's an exact example of the type of context you get from, I'll say, the more unstructured conversations that come through these digital interactions. And there's millions of these, and they're not inconsequential. I think cocoa data in the abstract doesn't actually give it the value that it is.

And if you think about someone talking about the trouble they're having to go see a specialty provider, maybe trouble with the medication maybe they alluded to something that's actually an important side effect of medication, but they didn't know it was important. All of those things are available when you have a digital front door that's an agent. And I think the important thing that you will have by leaning into this faster than others is you're starting to develop that advantage sooner. And because it compounds the earlier you start to develop that -- those memories in that context, the more your advantage will compound relative to your peers. So I really think this is especially in health care. I think this is incredibly important, also true of a property and county insurance company as well.

Well said. Thank you, Bret, so much. And as you said at the outset, I appreciate you being here, but above all our partnership.

Thank you very much. I appreciate it.

Thanks for being here.

I'm going to wrap here with 3 takeaways, reinforcing what you heard from me today. So first, we're creating meaningful value with AI now. Second, our health intelligence engine is allowing us to compound that value. And third, we are building where we differentiate, and we're partnering to accelerate, as you just heard from Bret Taylor, always with guardrails and safety and human accountability in mind. I started my talk today by saying that AI is just technology. And I will leave you at that point because that's what really matters. It's that context is how we achieve the vision you heard today. And for us, that's health intelligence, which makes complex care, more personalized, more effective and more affordable. Thank you.

Please welcome Dr. Amy Flaster.

Thank you, Katya. Thanks, everyone, for being with us today. My name is Dr. Amy Flaster and I'm the Chief Medical Officer of the Cigna Group. In addition to serving as the CMO, however, I'm also a practicing primary care physician. Every Friday morning, I go to my clinical office in Boston, where I take care of 350 adult patients. And every clinic session is different. I may be taking care of healthy patients seeking preventive care. I may be supporting people with chronic diseases or often, I'm supporting patients who have a new complex or specialty diagnosis as they begin to navigate their journey. It is this experience as a practicing doctor. That gives me a first-hand view into how our health care system today is working for patients and providers, where it's working well, and where there continue to be gaps and fragmentation.

As you've heard throughout the morning from my colleagues, we are at an inflection point, and the health care marketplace is demanding more, more personalization, more affordability and a more seamless experience. And this is why I'm so excited to share with you all today how our clinical capabilities uniquely position us to meet that demand and create differentiated value. To that end, there are 3 areas of clinical advantage that I'm going to focus on today. The first is the breadth and depth of our clinical enterprise with assets and capabilities that give us industry-leading scale and expertise to support complex patients. The second is the power of integration of those assets with our data. That unlocks precision insights, which allows us to provide better clinical outcomes and affordability. And third, I'm going to talk about how AI is creating a paradigm shift in clinical, allowing us to identify needs earlier, extend personalized support and improve outcomes for our patients at scale.

Let me take a step back and begin by grounding you in where we stand today. We have one of the broadest and deepest clinical ecosystems in health care, spanning our assets and capabilities that are in medical, in pharmacy, in specialty, in behavioral health and in our case management programs. And taken together, these capabilities allow us to support over 180 million customer interactions every year. We are fueled by the work and support and care provided by 5,500 clinicians. These are doctors, nurses, pharmacists and social workers that support our patients every day including, as Matt mentioned, 850 field-based nurses that provide boots on ground support. We have 24/7 availability of nurses and pharmacists to our members, and we conducted over 2 million visits a year through MD Live. It is this scale that has enabled us to develop differentiated expertise in complex patients.

Let me share 3 examples to bring this to life. Our transplant case management program in Cigna Healthcare supports members that are going to receive a solid organ transplant. So it's one of the most complex clinical journeys a person can undergo, and for the 6,000 members that are supported by this program each year and have our services wrapped around them, we see a reduction in the cost of care for each case of $87,000. A second example, Matt Perlberg earlier spoke to you about our TRCs, our therapeutic resource centers. You can think of these as specialty hubs of expertise, each focused on a different disease area. And to highlight on our rheumatoid arthritis and inflammatory TRC when supporting patients and wrapping nursing and pharmacy supports around them has been shown to reduce inpatient admissions by 22%, and overall medical costs by 8% by virtue of being supported with the TRC compared to nonspecialty care.

A third one to highlight. Earlier, Adam talked about the depth of our clinical services in our PBS business. And our Safeguard Rx capability, which combines specialized clinical programs, with value-based purchasing has been shown to increase medication adherence by 14.5% for people with chronic diseases. Each of the programs and capabilities that I've just described is impactful in its own right. But where there is integration across our enterprise is where we can derive the most clinical value for patients. And oncology is one compelling example of how this comes together. By leveraging our existing early cancer identification and engagement capabilities we are able to engage people with breast, colorectal and lung cancer, weeks and months earlier than we otherwise would be able to do.

And this earlier engagement is incredibly valuable, both clinically and financially. It gives us the opportunity to coordinate, support and case manage these patients before fragmentation, avoidable utilization and costs surface.

And the results you can see underscore this impact. When oncology patients are fully supported by our integrated model across our enterprise, we see a reduction of $28,000 per member per year in their cost of care. So to put a finer point on this, our earlier insights drive earlier action, and that earlier action drives better outcomes, both clinical and in terms of affordability.

So now I'm going to shift and talk a little bit about what comes next in our clinical model. And I'll say as CMO, as a practicing doc and as a patient like all of you, this is where it starts to get really exciting. I've just walked you through what we've built. We have over a decade of building one of the most deep and broad clinical enterprises in the industry. But today, AI creates a paradigm-shifting opportunity in our clinical model.

To take a step back for context around where clinical AI stands today, you can see a spectrum on the slide. On the left side of the spectrum, you can think of using clinical AI for administrative and back-office functions for more efficiency. This has become table stakes. On the right side of the spectrum are organizations using AI to support autonomous care. This is things like triage, diagnosis and even prescribing. And this is still untested and very much early stage.

Where we believe the greatest area of value capture exists is right in the middle of this spectrum, where we believe clinical AI can revolutionize patient support and navigation. And so this is where we are leaning in. Powered by our health intelligence engine that Katya just talked to you about, we are investing in the next generation of our clinical model, leveraging clinical AI to personalize care guidance and support for the most complex patients in service of Lead to One.

To this end, last week, we were really excited to announce a collaboration between the Cigna Group and OpenAI aimed at supercharging our work in clinical AI. We're combining the Cigna Group's strengths in caring for complex patients, our clinical programs and assets and our proprietary data with OpenAI's frontier AI capabilities and their consumer focus to enhance the support that we can offer to patients with complex conditions. And we've decided to start with oncology. Our 2 initial use cases are already underway. both of which are or will be embedded in our existing Accredo and Cigna Healthcare offerings.

In Accredo, a group of oncology nurses today are already using the Accredo clinical assistant tool, leveraging AI-enabled summaries of a patient's care journey before engaging the patient to improve personalization, quality of follow-up, efficiency and experience.

In Cigna Healthcare, Health Sense is the name of our next-generation personalized health experience. This tool allows us to support patients throughout their care journey and in between doctors' visits. It puts clinical expertise at the center and leverages data to identify needs earlier and connect patients to the right support.

Before I show you the tool, a hard line I want to emphasize. We use AI to augment but never to replace clinical expertise. Our clinical judgment remains with our clinicians and is supported by our clinical AI governance, our quality and safety protocols and our evidence-based medicine tools.

But with that said, I'm now pleased to show you how Health Sense looks and feels and how it is translating our clinical expertise, our integrated data and our AI capabilities into a new and novel experience for patients dealing with the most complex conditions. We will center this demo around Maya Jones.

Maya is a Cigna Healthcare patient. She's a 59-year-old mother of 2. She works full time. She's a caregiver for her aging parent. And Maya recently received a life-changing diagnosis of colon cancer, and she's starting her first chemo cycle of capecitabine and oxaliplatin, short form for that as CAPOX.

Maya provided consent to use the Health Sense tool to help her through her journey. And this tool, Health Sense, is able to use longitudinal insights and data about the patient, including her age, her gender and information about her kidney function to identify that she has a high likelihood of post-treatment side effects. And so once Maya starts her chemo, Health Sense proactively reaches out and checks in on her before she identifies any needs. Let's take a look.

As Maya engages with Health Sense, either through ambient listening or directly through the chat function, the tool is accurately recording her concerns and symptoms, providing support and using the information to build an evolving view of Maya's health journey, suggesting resources and education specific to her. Partway through her treatment journey, Maya is concerned about a symptom that she's experiencing. Health Sense identifies the need for additional support and offers Maya the option to connect with a Cigna nurse at no cost and in real time, and provides the nurse with relevant context for Maya's care journey.

Throughout Maya's chemo cycle, Health Sense is checking in with her regularly, providing personalized care and guidance to help Maya through this journey. And 4 months later, as treatment is wrapping up, Health Sense continues to serve as Maya's partner, guiding her each step of the way.

As you can see, clinical AI represents a significant paradigm shift that we can leverage to improve outcomes, enhance experience and lower cost of care. And we believe that we, at the Cigna Group, are uniquely positioned to realize that value at scale.

So as I wrap up, I'd like to leave you with 3 takeaways. The first is that our clinical enterprise is built for patients with complex conditions, and we have the breadth and depth of capabilities to support them through their care journeys end-to-end. The second is that our connected capabilities, data and insights and the integration between them allow us to drive better outcomes, greater value and a lower cost of care. And third, as you saw, we are leveraging AI across our businesses to achieve earlier clinical interventions and provide more personalized support at scale.

We are really excited about the next chapter of clinical at Cigna. Thank you.

Please welcome, Ann Dennison.

Good morning. Thank you all for being here with us today. I'm Ann Dennison, Chief Financial Officer of the Cigna Group. And I'm excited to be here this morning to talk to you about our deliberately shaped portfolio of 3 scaled businesses that are going to drive value for consumers, clients, patients and shareholders.

So over the next roughly 20 minutes or so, I'm going to cover 4 key themes. One, how we're building on a proven track record of disciplined execution and differentiated growth. Two, how the pillars that you heard about today, our core growth opportunities and our distinct capabilities, are going to drive sustainable long-term growth. Three, how we're launching a $3 billion multiyear productivity and efficiency initiative, a savings initiative to reduce costs and also to be able to invest back in the business. And finally, how our strong cash flow and our disciplined approach to capital deployment is going to support profitable returns -- profitable growth and returns.

So with that, this morning, we reaffirmed our full year 2026 adjusted EPS guidance of at least $30.45, along with some other metrics you can see on the right-hand side of the slide. Our excitement is built on a strong foundation. So with that -- with the $30.45 for 2026, we will have achieved -- at least $30.45, we will have achieved a 14% CAGR over the last decade. And within the last decade, we will have grown in every single year of the decade. That is truly unique and differentiated in our sector and peer set.

We recognize that recent years have been dynamic and have been challenging, and we have work to do to get back into our long-term growth algorithm. But I want to point out what you can see on the right-hand side of this slide, which is from '21 to '26, we grew at the highest rate in our peer set with the lowest amount of volatility. This looks similar if you do it over a 10-year period. And I think what this demonstrates is the resilience of our portfolio, our ability to adapt and how we are creating sustainable long-term value.

So this performance has translated into very strong cash flow. From '21 to '25, so that 5-year period, we generated $56 billion of cash flow from operations and from divestitures. We have consistently taken a disciplined approach to allocating that capital, balancing investments back in the business with returns to shareholders.

And so over this period, over that same 5-year period, we returned $36 billion or 64%, excuse me, of that cash to shareholders in the form of dividends and share repurchases. While at the same time we continued to invest in the business in order to drive organic growth and enhance our strategic capabilities.

As you heard from Brian Evanko this morning, we have deliberately shaped our portfolio of investments and businesses over the last near decade into 3 scaled growth businesses. So Cigna Healthcare represents 40% of the overall enterprise earnings, while Evernorth is 60%. But within Evernorth, Specialty Care is now 37% of overall enterprise earnings, versus 2 years ago, it was at 30%, and Pharmacy Benefit Services is 23% of overall enterprise earnings. Each business has distinct growth drivers and capabilities that create -- and we've created a balanced portfolio that is going to drive sustainable long-term growth.

So let's talk about why we believe that's true. Our portfolio of businesses is concentrated where -- our portfolio of businesses is positioned where health care costs are concentrating. You heard this throughout the morning. So you heard from Adam Kautzner how drug spend is becoming a bigger and bigger portion of health care spending. We are a market leader with scale, purchasing power and the ability to drive unit costs lower and deliver for our clients in that business. You heard from Matt Perlberg on Specialty and Care, how specialty medications are becoming a bigger and bigger portion of overall drug spending. We are a market leader in Specialty and Care with differentiated end-to-end capabilities that drive outcomes for patients, as you heard today, and better outcomes for our clients.

And you heard from Bryan Holgerson about how costs are concentrating in a relatively small number of patients with the most complex conditions and how we, as a business, are designed to serve those patients through our integrated model and drive better outcomes and affordability for our clients. So altogether, the combination of our businesses, we're improving affordability, we're driving better outcomes. And importantly, we are driving sustainable long-term growth.

This is why we are confident in our ability to deliver long-term annual adjusted EPS growth in the 10% to 14% range through 2040: our pillars of growth, our distinct capabilities and our disciplined execution.

Now I'm going to walk you through how we're going to deliver on that commitment. So I'll start with Evernorth.

Evernorth again represents 60% of enterprise earnings. An increasing portion of this business is shifting towards Specialty and Care, which is our highest growth opportunity business. As a result, we are confident in reaffirming Evernorth's long-term earnings growth algorithm of 5% to 8% through 2030.

Now let me break that down into the 2 businesses and talk a little bit about each of those. So first, I'll start with Specialty and Care. So again, 37% of overall enterprise earnings, higher growth business, large TAM, secular tailwinds, growing at high single digits, the TAM, you heard Matt talk about that earlier, differentiated end-to-end capabilities. All of those things make us confident in reaffirming our 8% to 12% growth algorithm on Specialty and Care.

If I break that down, 7% to 9% of that is what we think about as core growth, and you can think of that as aligned to the secular tailwinds. The other 1% to 3% of that is our differentiated capabilities, our opportunities to increase share and to take more of the TAM, particularly in the medical benefit space.

So now let's turn to Pharmacy Benefit Services. Pharmacy Benefit Services represents 23% of overall enterprise earnings. We are a market leader. We are driving innovation. We are driving affordability. We are in -- the business, and the industry, is in transition given the evolving regulatory landscape. We're on the front foot of that innovating with our new signature product. We do have some near-term headwinds, but we are confident in the outlook that we have of flat to 4% through 2030. We're confident that we're creating durable earnings -- a durable earnings profile that will be fee-based and predictable.

Our updated margin for the Evernorth segment is 3% to 3.5%. And this -- I just want to point out that this update reflects what we -- the dynamics that we've been talking about around our large client -- the 3 large clients and our renewals and extensions. That's what's reflected in the update as it relates to Evernorth margins. So to recap, we are confident in driving 5% to 8% long-term growth across the Evernorth segment, and I'll move on to Cigna Healthcare.

So shifting to Cigna Healthcare, 40% of our total enterprise earnings. We see substantial growth opportunities. You heard Bryan Holgerson talk through the dynamics there, the opportunities that are afforded to us through our integrated offerings. We see opportunities to grow in Select, but also to expand our positioning in middle markets and national. Our integrated data, our personalized care capabilities, our risk management expertise all reduce inefficiency across the broader health care industry and help meet our client needs. So with that, we expect average annual compounded earnings growth for Cigna Healthcare to be 6% to 9% through 2030.

If I break that down, 4% to 6% of that is core growth. And again, you could think about that as growing in line with the market. And then the other 2% to 3% of that is growth from our distinct capabilities, so our opportunities to increase our share in the select segment, our opportunities to continue to recapture margin as it relates to stop-loss and then our international business. Our international business represents just over 10% of the overall Cigna Healthcare earnings number, and that business is growing in the high single digits. For Cigna Healthcare, we expect long-term margins to be in the 10.5% to 11.5% range. That is consistent with our prior target.

Further bolstering our confidence in our ability to deliver on our growth outlook is our $3 billion multiyear modernization and productivity initiative. So for the sake of -- if you read any news articles that came out this morning that said that this was a spending initiative; this is a savings initiative. So we intend to drive productivity and efficiency from '26 through 2030 of $3 billion.

And so the 3 areas we're going to focus on within this program are: one, automating our workflows, finding opportunities to use AI or use technology or reengineer workflows. So that's one category. The second category is around talent, so building a future-ready workforce, for the most efficient and effective talent base. And then third is optimization of our supplier partner and vendor landscape.

As Katya noted earlier, technology and AI will accelerate these efforts. It will help improve productivity, lower our cost to serve, create operating leverage and provide additional capacity for us to invest in growth opportunities.

In a moment, I'm going to talk about how much growth we're expecting from capital deployment. But before I do that, I just want to spend a moment to talk about our capital deployment strategy and our philosophy. So I'll start with growth.

We believe our best investment that we can make is in ourselves. We are committed to a sustainable dividend. We're at about a 20% ratio and a 2% yield currently. We believe share repurchases are a highly attractive use of capital given our current valuation. And we have about $6 billion -- a little over $6 billion remaining under authorization today. We are strengthening our balance sheet, and we expect to be at our target of approximately 40% debt-to-cap by the end of this year, 2026.

And then lastly, M&A. Bolt-ons remain our focus, but our criteria for M&A has not changed. Any M&A that we look at has to be strategically aligned and financially attractive. So what does strategically aligned mean? To us, that is, it has to expand our reach or enhance our capabilities. Financially attractive, for us, that means it needs to deliver EPS accretion that is durable and visible to us and a strong return on invested capital. Importantly, our portfolio is strong and M&A is not necessary for us to achieve the commitments we're making here to today, but M&A can be an accelerant to our growth.

As we look forward, we expect continued strong cash flow generation and growth from capital deployment. We continue to expect 4 to 5 percentage points of average annual EPS growth from capital deployment. Over the 2026 to 2030 plan period, we expect to generate approximately $50 billion in cash flow from operations. And for context, that represents about 70% of our current market cap.

As we think about allocating that capital, 20% to 25% of that will go to investing back in the business to drive future opportunities, future growth. 20% of that will go towards supporting our dividend. And then the remaining 55% to 60% gives us an enormous amount of strategic flexibility to think about share repurchases, debt repayment and M&A.

So if I put it all together for you, we have a clear path to 10% to 14%. We expect durable operating earnings growth of 6% to 9% plus 4% to 5% from disciplined capital deployment. Our confidence is grounded in a portfolio that is aligned to attractive trends, differentiated capabilities and our relentless focus on operations and execution.

With this commitment, we have a clear path to deliver on an adjusted EPS floor of $45 per share by 2030. This is a simple depiction. This is everything at the low end of the growth ranges. And I want to stress $45 in 2030 is a floor, not our target and not our expectation.

But there's 2 important things I think that this slide highlights. One is that we are not relying on any one particular growth engine in order to achieve our objectives. Secondly, that we can meet this objective, the low end of the range, with our Pharmacy Benefit Services business staying flat through 2030. So this gives us confidence that we will deliver at least $45 by 2030.

So as I wrap up, I've got a few key messages and then 3 commitments that I would like to leave you with. One is on the takeaway side, we are building on a proven track record of disciplined execution and differentiated growth. Two, the opportunities that you've heard today from our business leaders and across the board set us up for driving sustainable long-term growth. Three, we have launched a multiyear initiative to save $3 billion, some of which we'll invest back in the business, but some of it will take to the bottom line. And finally, our strong cash flow generation and our disciplined capital deployment will give us significant flexibility to return -- to strengthen our business and provide returns -- attractive returns to shareholders.

So those strengths support a clear set of commitments, 3 commitments that I'll leave you with: 10% to 14% adjusted EPS CAGR through 2030, $3 billion of modernization and productivity improvements and approximately $50 billion of cash flow from operations through 2030.

So taken together, we are confident in our strategy, confident in our ability to execute and confident in the value that we can create for consumers, clients, patients and shareholders. Thank you.

We're going to pause for a short break. Our next session will begin in 15 minutes.

[Break]

Welcome back, everyone. I'd actually like to invite our team back to the stage. So we've got a nice block of time here for -- to get to your questions. You already have had an opportunity to some degree during the breaks to ask some of those questions.

Just a couple of things before we start Q&A. Obviously, raise your hands if you have a question and wait for me to call on you. And also please wait for a mic. We do have mic runners throughout the room here. I'd also ask yourself to limit yourself to one question so we can get to as many questions as possible today. And obviously, we can come back around to the extent that we do have time.

So with that, who would like the first question? Let's go to Ann.

Ann Hynes with Mizuho. So obviously, AI is a big focus, and there's a fear over time that it could lead to job market losses and things like that. So given your health care segment is very levered to the commercial market, how do you view the diversity of your membership base as we all kind of go through this AI transition over the next decade?

Good to see you. So as it relates to the overall composition of the Cigna Group, one of the important principles for us was to have strong focus on where we have a differentiated right to win, which is what led us to the 3 growth platforms we talked about this morning: our Specialty Care business, our PBS business, both within Evernorth, and then Cigna Healthcare, which is the balance of 40%. So those 3 growth platforms, importantly, we have a differentiated right to win in each of them. And you heard that through all of the presentations this morning.

So to your point, are there other addressable markets that we don't participate in today? Yes. Those have been deliberate focus choices for us. And you heard from Bryan, we continue to have tremendous growth runway within the select segment within the U.S. employer space. So we are not out of headroom in growing within our Cigna Healthcare business today.

Relative to AI potential and job disruption, which was underneath your question a bit, thus far, if you look year-to-date, the disenrollment within our Cigna Healthcare portfolio is lower in 2026 than it was in 2025. So despite some of the headline in media cycles around AI-driven job disruption, we're not seeing it, right? We are not seeing it at scale. In fact, our membership is holding up to an even greater degree than it was in '25 on that basis. Over the longer run, obviously, we always are looking at the portfolio through the portfolio shaping that I made reference to and we'll always evaluate the addressable markets we're in, the businesses we're in. But today, we're very focused on those 3 growth platforms where we feel we have a long-term right to win.

Let's go to A.J.

So when you think about the 10% to 14% growth, I know there's a couple of specific things. They may not be big enough to move the needle, but your exit of the public exchange markets going into next year, the [ eviCore ] review. Should we think of that as pretty even, the 10% to 14%? Or is there a step back next year because of some of those things?

And also maybe the context on the $3 billion of initiatives that you're putting in place today, is there some upfront spending that you have to do? Or how will that be realized over time? And is that embedded in the 10% to 14%? Or should we think of that just give you more confidence in hitting those numbers? Or should we think of that as potentially creating upside?

A.J., I'll start and then, Ann, if you want to pick up, there are multiparts to that question. So I'll do my best to get it all, A.J. So as you heard from the team, very confident in our ability to deliver 10% to 14% EPS growth through 2030 when you look at the multiple growth engines as well as the strong cash generation, which gives us multifaceted capital deployment to support that.

Now importantly, underneath that, to your point, the Accelerate to One series of modernization and productivity initiatives, that will generate $3 billion of cost savings for the enterprise by 2030. That will be cumulative cost savings by 2030 as a result of all the things that Ann covered earlier: streamlining decision-making, making the best use of technology to drive our cost structure down. A portion of that will get reinvested into the business and a portion of that will support the long-term financial commitment of 10% to 14%. So that's how I would encourage you to think about the Accelerate to One program in the context of our algorithm.

As it relates to 2027 specifically, consistent with our prior commentary, we continue to expect at least 10% EPS growth in 2027. And that comes off our reaffirmed 2026 outlook. And anything else you'd like to add?

You got it.

Let's go to Jason.

Jason Cassorla from Guggenheim. Just wanted to ask quickly on the $50 billion cash flow bridge over the next 5 years. Can you give us some of the puts and takes in context of the Signature model rollout, if that has any downward pressure on cash flow generation or if there's any incremental uptick of that? Or how do we think about cash flow generation off the Signature model?

Jason, I'll start and then, Ann and Adam, if the 2 of you want to chime in on this question at all. So we have a long tradition of generating strong cash flow, as Ann demonstrated. And that gives us the ability to deploy capital in a multifaceted way. We'll always continue to reinvest in the business first and foremost. We'll maintain a 20% payout ratio approximately on our dividend. And then we have the ability to deploy the balance to either share repurchase or strategic M&A.

So strong cash generation will continue. We expect $50 billion over the next 5 years from '26 to '30, which incorporates the Signature specific dynamics. Would you like to expand on that a bit, Ann?

Sure. So as Brian said, I think -- so we thought about Signature and the timing of the cash flows between manufacturers and our clients, and we talked a little bit about that earlier today. And all of that is reflected in those estimates. And so the $50 billion represents our best view of the 5-year plan and how Signature and the adoption rate and what that's going to mean from a cash flow dynamics perspective.

Let's go to Lisa up front here.

Lisa Gill, JPMorgan. Of course, I'm going to ask a pharmacy question. So as I think about the 0% to 4% that you're talking about between now and 2030, just really want to understand on each end, right? So what gets you to 0? What gets you to the 400 basis points better? How do we think about the conversion to Signature? Is that part of it that, initially, you won't make as much dollar value?

If I look, Adam, for example, the numbers that you put up, $2.3 billion of operating profit, $2.1 billion of scripts, that comes out to $1.24 a script. Is that like what you're looking to recapture in a Signature type of contract? Like how do I think about that, one?

And then just secondly, we didn't talk about 340B today. You and I talked a little bit about it over there. But I think there's a lot of questions in the market around changes around 340B and the impact on your pharmacy business.

So Adam, maybe you can start on the Signature specific, and then, Matt, you can pick up on the 340B aspect of the question.

Okay. Sure. Yes. Thanks for the question, Lisa. So from a Signature perspective, yes, we expect, given how the market is very dynamic right now, and it is evolving. And for the first time in a couple of decades, we're seeing a decline in the rebate model. We are transitioning. We're leading through that transition from an industry perspective. We expect during this transition, as we move many clients from a rebate model to a rebate-free model, that during that transition, we're going to see the ramp over that time period of the growth. As we transition more clients into the Signature model, we do expect, based off of the potential improved economics that we will see, as you'll see a more rebalancing, especially across the market where many of our clients today, we may actually see some improved profitability given the benefits that we went over of they're going to see real big benefits in terms of cost savings for their highest-cost patients and neutrality for them. But there's also some time value money components as well as was mentioned in the panel.

And so we expect based off of that and our ability around different solution sets, that we will continue to be able to successfully provide selling into our clients because they do add a lot of value that those components will create additional tailwinds, as will our ability as we're contracting and minimizing our risk.

So from a predictability perspective that I talked about quite a bit today, that means there are clients today that we lose money on, right? We've taken some risk. And in the future state, we'll be in a much more predictable perspective and we'll be able to eliminate some of that downside risk, which should provide us with some additional upward opportunity throughout that change curve that we're working through over the next 4 or 5 years.

And I'm happy to pick up on the 340B. So 340B, as you all know, has been a very long-standing program. I think it was created back in like the early '90s. And so it's been through a lot of different changes, legislative, regulatory over those years.

As it pertains to us, we participate as a contract pharmacy, but still a relatively small part of the business when you put it in the context of the overall Cigna Group. And you can think of we, for example, don't have retail pharmacies or a big retail presence. And so it becomes a relatively small part of our business, manageable in the context of the overall enterprise as well as contemplated in the 8% to 12% that we talked about in Specialty and Care.

Yes. Two quick wrap-up comments. My pointed to Matt because 340B contributions are reflected in our Specialty and Care segment specifically to Matt's point, relatively small part of the overall franchise. And to your question about the algorithm, Lisa, the 0% to 4% for PBS, we are not assuming any market share gains. So that if we do take share, would give upside relative to what's in our projection.

Let's go to Charles in the middle.

I wanted to follow up on specialty and maybe a little bit on that 340B part because you talked about kind of creating this new pharmacy network kind of connecting Credo with Shield. And the way I understand in 340B, right, Shield is helping hospitals to participate in the 340B program. And as restrictions from pharma is happening, 340B entities are trying to in-source more of those scripts to themselves, not sending out to a contract pharmacy.

If you're partnering -- so I would imagine that would be a headwind for Accredo as a contract pharmacy. Can you explain a little bit more how maybe this partnership changes that dynamic for you guys? Does this allow Accredo to still serve 340B entities and participate in that program to a greater extent than maybe just as a stand-alone contract pharmacy?

And then just in general on specialty, if I could, obviously, you talked about all the LEDs you're part of. Maybe in broad strokes, what are the big therapeutic categories that are important for Accredo that really kind of moves the needle? I know in other peers, people talk about oncology or other disease states. What -- you mentioned MS, for example, like what are the big ones that we should pay attention to and see pipeline of new drugs coming in and say, all right, this is a good tailwind for Accredo?

So a couple of different parts of the question. Let me first just pick up on the 340B point. So a couple of macro points that I would make. First, Accredo does participate as a contract pharmacy. But again, that's a relatively small part of the portfolio and manageable in the context of the current enterprise. That relationship doesn't change with respect to any pharmacy network that we're in with Shields or otherwise. So that's kind of the first point.

The second point, we're really excited about the Shields investment. And the reason we're excited about the Shields investment is because of those partnerships with hospitals and health systems and the fact that they're helping those hospitals and health systems run their specialty pharmacies. We do see that as an important growth vertical, particularly in that medical benefit space. I would note, though, that the way that we've structured the Shields relationship, it's -- we have a -- think of it as like a preferred equity stake, but it's not dependent on the earnings of Shield. So to the extent that there's fluctuations in that, that doesn't actually manifest itself into our P&L. So I would just kind of call that out. And we're excited about the pharmacy network, but I wouldn't call out anything specific to 340B with respect to that nor any changes in the relationship there.

As you go to limited distribution drugs, I mean, this is where -- this is an area where we really shine. We are the leader in limited distribution drugs. We have access to over 330. That is more than anybody else. And it includes over 30 products that are available exclusively at Accredo. In the limited distribution drug space, you tend to see that show up in the more rare drug space, drugs that tend to be smaller volume, they tend to be higher cost.

So I would look at, for example, the rare advanced therapies, gene therapies where we've seen quite a bit of growth in the LDD space. Oncology also is a sizable place for Accredo actually. It's about our -- I think it's our second largest therapeutic area, and it's an area where we see growth. You actually saw that in the video that we showed from [ Silvio ]. That was a manufacturer partner who brought an oncology product to market, and they chose Accredo as their exclusive pharmacy.

And a lot of the capabilities that we have, our clinical expertise as well as what we're building going forward with things like pharmacy forward, helping get patients started on therapy and keeping them on therapy is really important to manufacturers. And as we continue to extend our leadership position in that, that's why we have the confidence we'll continue to be a leader in that space as well.

Thanks, Matt. We're going to Justin all the way in the back. Let's get some back questions there.

Justin Lake from Wolfe Research. I wanted to follow up on Lisa's question around the PBM side of the business. You gave the example of the new contract in PBS at stable margins as contracts transition to a fee-based model. Yet you also talked about the earnings trajectory commentary seem to indicate that the next couple of years might be closer to the low end of that 0% to 4% growth.

First, do I have that right? And then if this transition isn't driving the lower margin, can you help us understand what is? For instance, you talked about the time value of money. Don't see much investment income running through the PBS business. Maybe you're talking about having to front the dollars and maybe there's like an interest expense cost there. But what drives you to the lower end, the 0 over the next couple of years on the PBS side?

Adam, do you want to start and Andy can pick up on the time value piece?

Sure. So as we've discussed this morning, there's, first, the transition of the business. And as we've indicated before, there are some smaller investments that are occurring as we work to transition the business as we're overhauling the entire supply chain. So we're recontracting the entire pharmaceutical manufacturer components and then certainly from a pharmacy perspective as well.

I'd characterize those negotiations on both sides going well. We're middle innings with pharmacies today. We're getting more and more pharmacies that are enrolling in our new cost-plus model. On the pharma side, -- we are having more of the larger manufacturers that we are gaining agreement on of how that's going to look future state. And much of where -- from a manufacturer perspective, there is going to be an element of a lot of that value that is coming directly to those patients taking high-cost drugs, that value is going to be provided from a manufacturer perspective in a more immediate term than it is today.

But there isn't an expectation that we're going to be supplementing that for a long term. Instead, it's going to be much more from a manufacturer perspective of providing much of that value upfront. And so as we transition through that period, we should start to see some additional opportunities longer term. We're also going to be extracting more value out of the market.

And our admin fee tied to the value that we provide or more closely to the value that we provide future state means that admin fee, there should be an opportunity for us to continue to provide a higher overall admin fee as we're extracting more value out of manufacturers and providing the best trend management in the business. And so those opportunities create a real opportunity for us to continue to ramp those earnings during that time period. But Ann, anything to add?

I think you covered it well. The only thing I would hit on, on margin that you didn't touch is just to remind you of the dynamics. So when we talk about the 3 large clients that we renewed, that's all sitting within -- for the most part, sitting within the PBM part of the business. And so when you look at it, there's a margin differential there between even the target margin.

And Justin, just to double-click on the timing of the 0% to 4% emergence to your first part of your question. If you remember the slide Adam showed that showed industry rebates PMPM growing for many years and actually declining in '26 and '27. That puts some modest pressure on our legacy economics in the PBM prior to signature models.

And similarly, we're seeing GLP-1 growth slow down. Those types of things put modest downward pressure. But the strength of Cigna Healthcare, the strength of our specialty business give us the 10-plus percent EPS growth for 2027 despite those dynamics. And then as Adam indicated, later in the decade, we'll start to see that growth rate increase.

We'll go to Elizabeth right up front.

Elizabeth Anderson from Evercore. One of the things you talked about today was the Evernorth wholesale business. Can you talk a little bit about sort of what are your expectations there? Is that distributing for Accredo? Is that mostly focused on hospitals? Is it more open than that? More details on that would be very helpful.

Absolutely. So broadly, we're really excited about CuraScript overall. I mean this is a $25 billion business. It's been growing at about 20% per year for the past 5 years, really, really strong performance. And we expect about $20 billion in new distribution revenue by the end of the decade. I would call out Evernorth wholesale as one of the things that drives that.

There's other drivers, too. We see organic growth, for example, we see growth in serving our own pharmacies, Accredo as well. We see growth in the hospital system channel with some of the capabilities that we've led as well as Evernorth wholesale. Evernorth wholesale is really exciting because what it allows us to do is get access to new medications that historically we haven't had access to within CuraScript. And so that helps us grow business with existing customers.

We have existing customers that buy those drugs or would like to buy those drugs and can now have access to that through us. And it will give us access to new customers who may want to use CuraScript or Evernorth wholesale, but historically haven't -- we don't have full line access to medications. And so this gives us another avenue to grow that business. So I would point to it as one of a number of areas of growth and part of why we feel really confident in the $20 billion of additional distribution revenue by 2030.

Let's come over to this side. Let's go to Lance. Let's wait for the mic here.

So just one quick follow-up on the pharmacy benefit services section and then I really want to ask about specialty a little more. On the PBS side, though, as you talk about pressure maybe as you transition over to Signature and whatnot, could you help to give investors a little confidence in why this would be a floor for margins?

And I think one thing that might be interesting is, obviously, you run a huge self-insured employer business. You're familiar with component elements of what these costs and returns and margins are for comparable businesses. So how do you guys get comfortable with that and then over on the specialty pharmacy side. If you could talk a little bit about in the growth in earnings that you see from the business, how much of that should we be thinking of as like revenue as opposed to earnings growth? So like what are biosimilars and generics doing so that we can kind of think that through and how that impacts margin?

And lastly, on that, what other sort of capabilities or white space do you still need or you see opportunity? Obviously, distributor you just talked about. But are there things in rare and orphan, are there particular conditions? Are there like particular aspects of infusion or something like that, that present opportunity for you?

Thank you for that one question, Lance.

Thanks, Lance. There's a lot in there. Maybe I'll start, and Adam, if you want to pile on, on the pharmacy benefit services piece and then Matt on the specialty component. To your point on margins, legacy models, signature models, A, we will have the pen on the underwriting of the pricing, which is very important. So Adam and's teams are working together on that.

Two, if you think about the value creators in terms of why clients work with us, they're the same in our legacy rebate-driven models as they are in our signature models, right? We deliver superior unit costs. We have great clinical programs that ensure medication adherence. We administer complex benefit designs. Same exact value creators in the legacy model as in the signature model. We'll get paid differently. So you heard Alicia when she was up here on the panel with Adam talking about administrative fees will go higher and employers are starting to understand and accept and embrace that. But we expect to target the same margin profile, legacy model, new model. Anything you'd add to that?

Only that it's recognized based off of where we're going to be able to lead the industry here that clients need a strategic partner. And in these times where they're seeing more unpredictability, they need a leader that's going to be able to shepherd them through those things. We are looked at today bar none as that leader. It's shown in the really high client retention rates that we're seeing in the mid-90s.

It's also demonstrated in the really strong new sales growth that we continue to see that is profitable, that is hitting target margins to Brian's point on having control of the pin there. And we're continuing to be able to lead from a thought leadership perspective. So not only are we looked at today as being the right partner now even with the unpredictability and uncertainty around some of the rebate components, which is putting a small amount of pressure on our earnings. But from a growth potential long term, we're looked at as the right partner because we are going to continue to deliver real value to those clients from a strategic perspective and be able to keep that cost curve in check for them.

And then to the second part of the question, if I think about just the earnings growth in specialty. So first, we reaffirmed today 8% to 12% long-term annual earnings growth. We're confident in that. We've actually, over the past 2 years, delivered at the high end of that range. And we have -- and that's a combination of both the secular growth that we see as well as the specific capabilities that we have that differentiate us that allow us to grow even beyond the secular growth that we see.

There's a couple of things that are driving the overall market growth. So if you step back at the $480 billion market, that market has been growing in the high single digits, and we expect that to continue. There's a couple of things driving that. One is just new drugs coming to market. So the pipeline is very strong. I think north of 70% of the drugs that are approved by the FDA last year were specialty drugs, and we expect that growth will continue. We also see a lot of growth just in the existing medications.

And we're seeing, for example, doctors, in some cases, moving to specialty medications earlier in treatment as a frontline therapy as opposed to, in some cases, after multiple attempts at a traditional medication. So all of that leads to the secular growth in the space. Biosimilars, as you mentioned, they offer savings opportunities. So it tends to have a negative effect on revenue, but it expands earnings.

And importantly, it's a savings opportunity for patients and plan sponsors. And because of our model of alignment with them, that actually helps fuel our growth as well. And so the strong biosimilar pipeline we see is another fuel for earnings growth. We expect about $100 billion in annual spend to face new competition by 2030. You asked a part of the question on additional capabilities. So importantly, we don't feel like we need additional capabilities in order to achieve that 8% to 12%. We're really confident in the capabilities we have, both in the pharmacy and medical benefit space.

Having said that, we do see the increased growth in the medical benefit space as a tailwind for us. And the fact that we have CuraScript that's been growing the way it's been growing, the recent acquisition of CarePath as well as the investment in Shield, we think that combination of capabilities across pharmacy and medical is a differentiator for us, all of which gives us the confidence in that 8% to 12%...

Let's go to Kevin right in the middle.

Kevin Fischbeck from BofA. Just want to go to the PBM side of things. I think there's just a lot of concern about the timing of legislation and how it's going to impact profitability. I think there's always concern when it comes to PBMs that there's another shoe to drop. But it sounds like you're saying that '26 '27 maybe is kind of the bottom from a margin perspective, you actually be accelerating even as the legislation starts to take effect and customers are increasingly buying these programs.

So just if you haven't actually contracted yet, the amount of visibility that you have on that trajectory of improving margins over the next couple of years. And then when we think about that 0% to 4% number, if you -- how much of that is just margin improvement versus revenue growth? It doesn't sound like there's actually much revenue growth because right now, you're making these investments in the transition. So margins are below average in '26 versus where the target margin is, say, in 2030. So I just want to understand kind of the math behind 0% to 4%, what kind of revenue growth that assumes versus margins?

I appreciate all those questions, Kevin. I'll start, and Adam, you can jump in on this. So on the latter part of your question, you should think of the signature model will be a fee-based simple from an analytical standpoint, a simple model to understand. It will be easier for all of you to model, easier to understand what's happening relative to the conversion of customers to revenue and earnings once we're fully scaled.

We're going through a migration period, as you know, right? '28 is when we'll start to scale. We'll have 50% of eligible lives in that by the end of '28, and it will grow thereafter. So to your point, margins right now are somewhat depressed in our PBS business as we're making investments in Signature as well as some of those industry-wide dynamics that I referenced earlier. So we will see some level of margin expansion through the balance of the decade in that business.

Now Adam and his team are doing a tremendous amount of work to build out our signature model. So you shouldn't think of as we're starting from 0. There's actually quite a bit of discussion happening with manufacturers, discussions with potential clients, discussions with existing clients. So do you want to pick up on where we are?

Sure. Yes. So interest remains high. as we've covered, 2028 is when Signature will go live. Cigna's fully insured block will go live next year within the Signature model. We already have clients that are looking for more transparent, simplified fee models. And so we're transitioning clients now into those types of models. There's the high interest within Signature.

We are seeing where full pass-through models, a definite movement towards much higher administrative fees because it's offset by full transparency of the value that's going through. So we remain confident in our ability to successfully transition clients the 50% or more of our members, which will be transitioned by the end of 2028 into those types of models. And the market itself, you can feel it shifting where we were back in October of last year, making an announcement, there was certainly a lot of skepticism around a rebate-free model.

But we have spent a year before preparing for it. We had the tracks laid as we work through with manufacturers and with pharmacies, and that's all progressing. So we are on track to be able to deliver it. Interest will remain high. We'll be able to transition. And keep in mind, there is clarity in the market today. So we have an FTC settlement. We have the CAA, which will go into effect in August of 2028.

So we know what those components are from a federal landscape perspective, and we're executing against those to give the assurances to our clients that they will have CAA compliance and we'll see strong adoption because the whole market is going to have to make decisions at that point of do they want to stay with the CAA-compliant legacy rebate model, which we will have available or what our new standard is from a signature perspective. But either way, we remain confident then that we'll be able to grow to the higher end of that 0% to 4% range as you get into those outer years.

Let's go to Michael Ha.

Michael Ha from Baird. Just wanted to double-click on Signature. So when you describe margins as being preserved under Signature, does that also mean comparable earnings per member, assuming the same utilization and drug mix? Or should we distinguish between preserving margins versus preserving earnings dollars? And to Brian's point about the rebate pool shrinking for your legacy business, do you have contractual flexibilities around fees or other terms to help -- like within the contract period to help preserve earnings? Or do you really have to just wait until repricing in the new contract renewal?

Adam, are you okay to share on that?

Yes. So from a rebate perspective, to hit the back end of your question, we're managing our guarantees today, and they are in line with our expectations. And we do have adjustments where needed to be able to work with our clients to make those adjustments when market events do occur. And so we've been able to manage through that. It's manageable today.

We expect to continue to be manageable through Inflation Reduction Act types of components throughout the time period or MSN adjustments. So that part is not a concern. From an overall earnings perspective, we do expect to have an earnings level that is consistent with where we are today for the future state and some new opportunities around the overall earnings.

So I wouldn't expect that you're going to see -- you'll actually see more predictability as we're able to mitigate more of the downside risk within Signature because we'll have a predictable, stable level within the potential to grow off of that by selling in new solutions and products. And those products are priced based off of the value that we deliver.

And so as we continue to deliver more value and as costs continue to go up in terms of high-cost specialty drugs, that means we're going to continue to be able to deliver more value and the effective solutions that we put into place, which means we'll be able to then be compensated at a higher amount for those, which should continue to then ramp. We'll leverage value-based solutions as we do today.

They may look different than our SafeGuardRx portfolio that we've been really successful with where we have over 60 million of our lives enrolled in those programs. But that type of chassis is what we will utilize into the future. So those components don't go away. They'll just be leveraged in a different form and still be able to deliver on the durability of the earnings. Ann, anything to add?

Can we go to Erin, right up front here.

Erin Wright, Morgan Stanley. As you think about the medical benefit being the next leg of growth in specialty, I guess, do you see the need to own or partner more closely with an MSO? And is that -- or other provider-facing assets just to capture more of that opportunity at CuraScript or otherwise? Do you need to own that entity to fully recognize that? And then also, as you think about private label biosimilars in Part B arena, are you limited on that front at all? Or how can you participate there as well?

So probably worth noting, if you step back, we do see a lot of growth potential in that medical benefit space, and we have a leadership position in pharmacy today, but we have a collection of assets that we're really excited about, CuraScript being the largest, Carepath and our investment in Shield. And the combination of that, we feel we'll be able to deliver outsized growth in that medical benefit space. It's probably worth noting, we partner with providers quite a bit today. I mean CuraScript serves about 12,000 providers, physicians' offices, infusion centers, hospitals and health systems.

And then our acquisition of Carepath as well as the investment in Shields gives us partnerships with many more hospitals and health systems as well. So we have a really, really good provider chassis today through partnership. I would say we feel like we have the assets that we need in order to compete in that space. And we're really excited about that. We've already been delivering CuraScript for the last several years, 20% year-over-year growth.

We said that we expect about $20 billion in new distribution revenue, and we're really confident that, that will help us grow in that space as well as be part of the 8% to 12%. As it pertains to private label biosimilars, I would say this is really one example where the collection of assets that we have across the Cigna Group is really impactful. So we have Cigna Healthcare, we have our pharmacy benefits business. We have our specialty pharmacy, and we also have our specialty distribution and provider businesses.

If you think about the collection of all of that as we start seeing now biosimilars, as you mentioned, in the medical benefit space, that's just another chassis that we have to help drive savings for patients, savings for providers as well as help fuel our growth as well. So we're actually really excited and bullish about that opportunity. And it really comes down to that collection of assets that are pretty unique to the Cigna Group.

We'll go to Steve Baxter all the way in the back there.

I was hoping you could speak a little bit about the competitive landscape in the PBM space. I there's a perception that alternative PBMs have gained a lot of momentum over the past couple of years, and they're competing on fee structure, transparency. And also, I think there's a perception that pricing is part of the reason that they're winning in the market. I guess the model change addresses transparency and fee structure. But how would you describe how you expect the competitive dynamics with these alternative PBMs to play out?

Matt and Adam, you guys are popular today on our panel. So we had our best selling season in 2027 in several years in PBM, which speaks to the robust nature of the value prop we're able to deliver against some of those alternative PBMs as well as the larger, more scaled competitors. Adam, maybe you can pick up a little bit more on how you see the competitive landscape going forward?

Sure. So it is a highly dynamic market today. As Brian mentioned, though, we've had the best selling season in quite some time, especially when you look -- if you take out mega clients and you look at the breadth and depth of what we're selling across government programs, labor and small middle market and even large market. And some of those wins are coming from some of the smaller PBMs as win backs where they went expecting something new and didn't get what they thought they were going to be delivered on.

And what clients are looking for, what wins today and what won tomorrow and win in the future is still the consistency of can you address affordability? Can you simplify the model from an accessibility perspective? And can you still deliver best-in-class transparency. Our current model does those things exceptionally well, and we're offering best-in-class economics given our size and scale and the 117 million Americans that we already serve today.

We're leveraging that as we move forward with our new model as well, improving the level of transparency with our clients. They're looking for that strategic partner. What we've also done is really proud of our people, and we're bringing out the expertise of our people out into the market that work on these things every day. We've got a leadership team with decades of experience.

And it's that type of knowledge across clinical, financial and being able to truly create new innovative solutions that we are recognized as a continued leader in the market, and that's where we continue to shine. And so I remain confident on where we are today, regardless of who we're competing against and what we're going to be up against in the future as well. But that's why we continue to see high client retention and profitable new sales growth.

Let's go to George.

George Hill from DB. I wondered if we could talk a little bit more about the biosimilar rebate dynamic. You had mentioned, if I heard you correctly, that the lower rebates and biosimilars are putting pressure on clients and there's some sensitivity in the decision-making process.

I assume that this is the increased use of biosimilars is going to drive margin expansion in the specialty space, but I would also assume that clients are most concerned with lower drug costs, though I think many of us are sensitive to the rebate dynamic. I would just love if you could just spend a little more time on what is the client sensitivity around the changes in rebates as biosimilars get adopted versus what happens on the brand side and again, the margin contribution?

Sure. I'll start, George, and then Adam, if you want to talk about the client side and Matt, if you have anything you want to sweep relative to the biosimilar contribution. So as you think about our portfolio in Evernorth, branded drugs with rebates. So take HUMIRA is a good example. The contribution of that financially would show up in our pharmacy benefit services business that Adam oversees, right, the 23% of the company's earnings.

When HUMIRA biosimilars were available, we made a full court press toward moving as many patients as possible into the biosimilar with a $0 patient out-of-pocket, much lower net cost to the plan sponsor, whether that be an employer or a health plan. The contribution of the biosimilars ends up in the Specialty and care segment. So if a previous HUMIRA script would have been in Adam's P&L, the biosimilar now is up in Matt's P&L, right?

And it's a good thing for the patient because they get a $0 out of pocket. It's a good thing for the employer or the health plan because they get a lower net price. So to your point, at the end of the day, the lowest net price is what rules the day, and that's been the orientation we've used around biosimilar adoption. Anything else on the client side, Adam?

Yes. I think on the client side, clients are -- they've been used to growing rebates, right, for the last couple of decades. And so with like the largest drug in the world, HUMIRA going biosimilar, they're used to evaluating us in terms of different guarantees and rebate guarantees are a primary driver of making decisions. And those rebate guarantees today are now flexible. But what they're realizing is much better overall net cost savings. So there's a win for clients. They've just got to evaluate it differently.

And so that's what [ Alicia ] has to explain of -- she's on the panel today and you're getting a net win here, but it's how do we make sure that an organization like us has been really successful at transitioning more patients to biosimilars, how we're not penalized and evaluating us versus others from a competitive perspective. So this actually is moving the market into a much more positive direction, which is focus on true net cost and less on guarantees. We'll be successful either way, but I think it's a much better place to go of you're saving patients' money, you're saving clients' money at the end of the day, that's the best thing, and we're extracting more money out of manufacturers in these types of new environments.

Maybe we'll take one more, Sarah.

Sarah James, Cantor. At the midpoint, there's about 170 bps of the long-range projection that's driven by above-market growth. Hoping you can double-click on a couple of the assumptions underpinning that. So the first 70 bps or the 1% to 3% from Specialty Care services, what medical benefit share gain assumptions is that based on? And how did that fare in 2027 versus that baseline? And then second, there's about 100 bps to enterprise or 2% to 3% to the segment in health care. Can you scale the buckets of how much of that is Select versus international and Stop Loss?

Sure. Thanks for the question, Sarah. I'll start and maybe Matt and Bryan, we can do a tag team on the specialty and the Cigna Healthcare assumptions. So as you heard throughout the day, we talked about our 3-pillar growth framework of delivering core growth, leveraging distinct capabilities, executing with discipline. So the above-market growth falls squarely where we're leveraging distinct capabilities.

So in the case of specialty, it's all the things you heard from Matt, the network of clean rooms, industry-leading LDD access, great patient experiences, manufacturer relationships, et cetera. In the case of Cigna Healthcare, the affordability gains that Brian talked through will drive our ability along with the funding-agnostic model. So would you guys mind putting a little bit more of a finer point on that?

You definitely hit the highlights. I think stepping back, the 8% to 12%, we're reaffirming that long-term annual earnings growth today, but we've grown at the high end of that for the past several years. And that's because of the combination of capabilities that we talked about, the clinical expertise we have, the leading access to medications as well as the supply chain advantage that we have.

That includes capabilities across the pharmacy benefit space. It also includes capabilities across the medical benefits space. So while we would see outsized growth in the medical benefit space, I wouldn't just highlight that as the only area of reasons why we feel confident beyond the secular growth. It's really the combination of capabilities that we have across all of those that gives us that confidence.

Yes. And as it relates to Cigna Healthcare, there's 2 pieces. You mentioned both of them, Stop Loss and you mentioned Select. I'll add one more. As it relates to Stop Loss, we commented that we have 100 basis points of margin recapture. The majority of that's in '26. We're on path for that. There will be a remainder that happens in '27. Beyond that, the growth that we expect in '27 is both in our middle market and in Select. I mentioned earlier the outsized earnings that Select drives. So as we grow into Select in '26 or as we grow into Select in '27, you'll continue to see that carry over from a margin standpoint as well.

Okay. That concludes the Q&A session. I'm going to ask our leadership team to step down, and we can move to Brian's close. Again, I appreciate everyone's question and engagement there.

Thanks, Ralph. And thanks, everybody. I really appreciate the detailed questions you just asked and the level of interest you demonstrated throughout the day today. Hopefully, you heard from our team, the passion, the confidence, the level of engagement we have with one another and the way both we deliver value to the market, but also the culture we have. So hopefully, that was evident to you throughout the time this morning. So thanks for prioritizing this. We really do appreciate it.

Just to recap a few key points. You heard my opening throughout the day, we talked about our Lead to One vision. This is our unifying enterprise vision for delivering personalization at scale for all the customers and patients we serve across all of our businesses, whether they're healthy today or whether they have complex health care needs. So again, the essence of Lead to One is personalization at scale. And you heard about this vision being enabled by our strategic growth framework, delivering core growth, leveraging distinct capabilities and executing with discipline. We talked about one team, the fact that all of our employees are aligned around serving the customers and patients holistically that we have the privilege to serve.

And we talked about Accelerate to One, which is our $3 billion multiyear savings initiative through driving modernization and productivity across the organization, a portion of which will make our products and services more cost competitive in the market and a portion of which will support our financial commitments over the longer run.

Now you also heard quite a bit of focus from us on complex health care needs. And we talked about how just 8% of patients have complex health care needs, yet that represents 55% of all the health care spending and how our intentionally built portfolio across the Cigna Group leads to an even higher percentage of the spending we impact being associated with complex care. And we discussed the leadership position that we've carved out over a period of years and decades, specifically in serving those individuals who have complex health care needs. And that includes our Specialty and Care Services segment, which now represents 37% of the company's total income, up from just 30% at our last Investor Day.

So taken all together, hopefully, you would agree the Cigna Group is a compelling long-term investment. We're positioned in the areas of health care where both needs and spending are concentrated today and are growing rapidly. We have competitive advantages specifically in serving those patients who have complex health care needs. And our Lead to One vision unifies all of our 60,000-plus colleagues around serving customers and patients uniquely and driving personalization at scale.

The deliberately shaped portfolio includes business unit expertise, like you heard today from Brian, Matt and Adam, along with reinforcing enterprise capabilities, as you heard from Amy, Katya and Ann. We have a track record of executing operational excellence as well as financial discipline with strong capital stewardship. All of these capabilities give us a long-term runway for durable growth and shareholder value creation. So thank you for your attention. I really enjoyed the interaction today, and I hope you all have a great afternoon. Thanks again.

Ladies and gentlemen, thank you for standing by for The Cigna Group's Second Quarter 2026 Results Review.

[Operator Instructions]

As a reminder, ladies and gentlemen, this conference, including the Q&A session, is being recorded.

We'll begin by turning the conference over to Ralph Giacobbe. Please go ahead.

Great. Thank you. Good morning, everyone. Thanks for joining today's call. I'm Ralph Giacobbe, Senior Vice President of Investor Relations. With me on the line this morning are Brian Evanko, The Cigna Group's President and Chief Executive Officer; and Ann Dennison, Chief Financial Officer.

In our remarks today, Brian and Ann will cover a number of topics, including our second quarter 2026 financial results and our financial outlook for 2026. Following their prepared remarks, Brian and Ann will be available for Q&A.

As noted in our earnings release, when describing our financial results, we use certain financial measures, including adjusted income from operations and adjusted revenues, which are not determined in accordance with accounting principles generally accepted in the United States, otherwise known as GAAP. A reconciliation of these measures to the most 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 thecignagroup.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 2026 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 to today's earnings release and in our most recent reports filed with the SEC.

Regarding our results in the second quarter, we recorded after-tax special item charges of $153 million or $0.58 per share. Details of the special items are included in our quarterly financial supplement. Additionally, please note that when we make prospective comments regarding financial performance, including our full year 2026 outlook we will do so on a basis that includes the potential impact of future share repurchases and anticipated 2026 dividends.

With that, I'll turn the call over to Brian.

Thanks, Ralph. Good morning, everyone, and thank you for joining our call. I'm pleased to share we delivered strong performance in the second quarter as we continue to execute at a high level, drive results and accelerate momentum across our enterprise. Today, I'll discuss our performance for the quarter and key strategic drivers of our growth and demonstrate how the strength and durable nature of our model is fueling our success. I'll also share some examples of how we are leveraging data, AI and technology to deliver more personalized health care experiences for our customers and patients. Then Ann will review additional details about our results and outlook for the rest of the year. And we'll take your questions.

So let's get started. As I've stepped into the CEO role, I'm energized by our strategic direction, our execution and the impact we're having for those we serve, while leveraging the power of one of the most experienced leadership teams in the industry. Over the past few months, I've been spending even more time carefully listening to our partners across the health care system, including clients, customers, health care professionals and brokers. Throughout these conversations, a few themes consistently emerge. First, an elevated focus on affordability as new expensive therapies continue to enter the market and demand for complex care grows. Second, growing expectations from our personalized experiences as people want health care to feel as easy as other areas of their lives. And third, the need for actionable insights and clinical programs to keep people healthy.

These themes within health care are coupled with continued economic pressures, geopolitical uncertainty and a rapid pace of change fueled by AI advances. While the current environment is certainly dynamic, I see the landscape as ripe with opportunity to innovate, drive change and forge a new path in health care all while continuing to execute on our commitments today. This orientation has fueled our strong second quarter performance, where I'm pleased to report that both Evernorth and Cigna Healthcare results were ahead of expectations.

In the second quarter, The Cigna Group delivered total revenues of $71.7 billion and adjusted earnings per share of $7.78, all while we continue to reinvest in our business to fund growth, expansion and innovation for our customers. I'm proud of our team around the world for continuing to focus on those we serve. Our strategy is aligned with what customers and patients need most. And our portfolio is purpose-built for where health care is headed and its relevance has never been greater.

Now looking at our performance across our businesses, we continue to drive impact and growth across both Evernorth Health Services and Cigna Healthcare. Overall, Evernorth's earnings were slightly ahead of expectations, with revenues increasing 6% year-over-year, reflecting the continued demand for our services while we invest in broadening our offerings and expanding our reach.

Our Specialty and Care Services businesses delivered pretax adjusted earnings growth of 22% year-over-year, fueled by secular tailwinds as well as the differentiated strengths in Accredo and our expanded suite of specialty pharmacy services that support hospitals and health systems. This quarter, we also saw faster-than-expected adoption of specialty generics and biosimilars both of which improve affordability for patients and clients.

Our growth in Specialty continues to be fueled by our unique portfolio capabilities, which enables us to better serve patients with more complex clinically intensive needs. We're seeing continued growth in the number of patients relying on Specialty medications, and we are uniquely positioned to serve them with our market-leading access to more than 330 limited distribution medicines. Our highly personalized capabilities, including our clinical care teams, tailored engagement and deep understanding of complex health journeys distinguish us in our ability to serve these patients.

Turning to our Evernorth Pharmacy Benefit Services business. We delivered pretax adjusted earnings of $609 million, reflecting the impacts of the previously discussed renewals and extensions of large client contracts as well as investments to support the transition to our new rebate-free model, which we call Signature. The team is making strong progress in the build-out of our Signature Pharmacy benefits model. We see significant early interest from health plans and employers as we prepare for our broader market launch in 2028. This will follow our important next step of introducing Signature to Cigna Healthcare's fully insured plans next year.

At the same time, we're adding value and winning business today with 2027 representing one of our strongest selling seasons in recent years. We've been able to achieve this performance in pharmacy benefit services through our winning combination of superior unit costs, clinical programs designed to improve adherence to therapies and market-leading innovations that help our clients anticipate what is around the corner in a rapidly changing environment, helping them build and tailor solutions to meet their needs today while planning for the future.

Turning to Cigna Healthcare. We delivered results ahead of expectations with pretax adjusted earnings growth of 17%. While the needs of every client are unique, several factors contribute to why we continue to win in this segment. Our deep focus on the employer-sponsored health care market, where we have differentiated expertise, generating continued customer growth in our U.S. employer business. Our disciplined pricing and execution, including in our stop loss business where we continue to make progress on margin recapture, our strategic portfolio shaping to drive focus, our ability to continuously find new ways to innovate by leveraging data and clinical programs that keep people healthy and our integrated solutions that provide improved access and coordination across medical, pharmacy and behavioral health services.

For example, given the growing demand for mental health services, our most recent solutions demonstrate our continued industry leadership and make us the partner of choice. Our provider matching capabilities for behavioral health patients are reducing costs by matching patients with high-quality providers. And offerings like Headspace are expanding access to lower acuity behavioral health options, improving affordability, encouraging earlier intervention and complementing demand for outpatient services. As you can see, a consistent reason why we win in both Evernorth and Cigna Healthcare is our ability to innovate to meet evolving customer and client demands.

Now I want to spend a few minutes sharing more about how we are applying data, technology and AI to improve customer outcomes and transform business models. Our AI approach is built on a simple principle, start with the customer and patient and identify where innovation can drive the most meaningful impact for them. We are leveraging technology and AI to drive better health outcomes, simplify and personalize customer experiences and lower costs and then execute that at scale. This has enabled us to use AI to change the trajectory of the most complex clinical journeys to improve the lives of our customers and patients.

One example is Pharmacy Forward, our recently announced AI-powered program designed to improve how patients access and incorporate specialty medications into their treatment plans. We are unlocking new ways to coordinate care for patients by shortening the time between when a patient receives their prescription and when they can begin treatment, while minimizing administrative friction along the way. With Pharmacy Forward, we're focused on personalizing support, streamlining processing and helping patients start and stay on therapy with greater ease and confidence. Our targeted use of AI is expected to cut time to therapy in half on average.

And for clinicians, it enables them to deliver more connected, informed support, reducing their documentation time by up to 50%, freeing capacity to spend more time on patient care.

We'll find the same philosophy within Cigna Healthcare. We know patients navigating complex conditions benefit from personalized clinical support to improve both outcomes and affordability. This month, we announced an expansion of our AI-enabled care coordination capabilities to help us identify customers with emerging, complex or chronic health needs earlier such as cancer, heart disease and high-risk pregnancies and connect them more quickly to the personalized clinical support they need. Through predictive models and AI-enabled insights, we would be able to expand support to 20% more customers with emerging complex health needs. This is not about replacing clinicians with technology, but helping clinicians spend more time where they can make the greatest difference.

And the results speak for themselves. Customers who engage in these programs reduce medical costs by approximately $2,000 per year on average. Early engagement has already yielded a 42% reduction in avoidable inpatient stays amongst those customers.

What makes these efforts unique is that they're not stand-alone technology initiatives. They are enabled by the combination of data, clinical expertise and pharmacy capabilities that exist across our enterprise, all focused on better serving our customers. We believe this ability to connect insights with action and action with measurable outcomes is a significant competitive advantage for The Cigna Group.

As we look ahead, we'll continue to focus our investments on meaningful applications of AI that improve affordability, enhance the customer experience, help clinicians work more effectively and create long-term value.

Now let me summarize our results. We have a proven track record of delivering differentiated value for those we serve by innovating new solutions like Signature, Clarity, Pharmacy Forward, and Personalized Care Coordination as well as through our flexible model and meaningful partnerships. As a result, in the second quarter, we delivered on our financial commitments with adjusted EPS of $7.78 and are pleased to increase our guidance for full year adjusted earnings per share to at least $30.45. Further, our company has attractive sustainable growth opportunities in the long term, building on our history and track record of results delivery. Overall, our strong performance and disciplined execution throughout the first half of the year reflects the intentional design of our company and the passion of our coworkers for serving our customers.

With that, I'd like to turn it over to Ann.

Thanks, Brian. Good morning, everyone. As Brian mentioned, our second quarter results reflect another quarter of strong execution for the enterprise with both Evernorth and Cigna Healthcare delivering pretax adjusted earnings above expectations.

During the second quarter, we delivered total revenues of $71.7 billion, adjusted after-tax earnings of $2.1 billion and adjusted earnings per share of $7.78. With our strong second quarter performance, we are raising our full year 2026 adjusted earnings per share outlook to at least $30.45. This outlook reflects the strong first half performance while maintaining a prudent view of the current environment.

Now turning to our segment results. I'll start with Evernorth. Second quarter 2026 revenues grew 6% year-over-year to $61.5 billion and pretax adjusted earnings were $1.7 billion. Specialty & Care Services delivered strong performance with pretax adjusted earnings growing 22% year-over-year to $1.1 billion, ahead of expectations. The year-over-year growth reflects the strength of our Specialty businesses supported by continued specialty utilization growth and increased biosimilar adoption. Additionally, we were successful in improving the penetration of Specialty generics, including generic Revlimid. The highest penetration of biosimilars and Specialty Generics drives affordability and value to patients and clients and contributed favorably to earnings in the quarter.

Year-over-year earnings growth was further augmented by operating efficiencies and the income from our investment in Shields Health Solutions which expands our reach into hospitals and health systems. The sustained growth in our Specialty & Care Services business reinforces our confidence in the long-term growth opportunity within Specialty and reflects the deliberate steps we've taken to position our company at the forefront of this attractive market.

Within Pharmacy Benefit Services, pretax adjusted earnings were $609 million, down from the prior year, broadly as expected. Our performance reflects the previously discussed renewals and extensions of large client contracts and investments associated with the transition to our Signature rebate-free model. As we previously mentioned, we saw higher biosimilar and specialty generic adoption during the quarter, which benefited Evernorth's results, driving increased contribution in Specialty & Care Services while reducing contributions in Pharmacy Benefit Services.

Additionally, in the second quarter, we observed moderating GLP-1 growth as coverage level slightly declined and utilization growth slowed from elevated levels experienced in prior periods. We expect this trend to continue throughout the remainder of the year, and it is contemplated in our full year outlook. Overall, Evernorth's second quarter results reflect the continued strength of our Specialty & Care Services business alongside progress in the evolution of our Pharmacy Benefit Services business.

Turning to Cigna Healthcare. Second quarter 2026 revenues grew 10% year-over-year to $11.8 billion, and pretax adjusted earnings were $1.3 billion. The medical care ratio for the second quarter was 84.5%, slightly ahead of expectations. Cigna Healthcare delivered results ahead of expectations, driven by strong performance within the U.S. employer business. Broadly, overall cost trends remain elevated but stable. Against that backdrop, medical cost trends were slightly favorable to expectations during the quarter, reflecting lower outpatient trends, including lower surgical spend. Additionally, we continue to see good traction in the employer market with medical membership growing year-to-date, reflecting the strength of our client relationships and the value of our offerings.

Overall, we are pleased with Cigna Healthcare's performance, which reflects our disciplined pricing, effective care coordination and focused execution.

Now turning to our outlook for the full year 2026. The strength of our second quarter performance gives us the confidence to increase our full year adjusted earnings per share outlook to at least $30.45 while maintaining a disciplined and prudent approach to the full year. Regarding the earnings cadence, we expect second half adjusted earnings per share to be split roughly evenly between the third and fourth quarter. Within Evernorth, we continue to expect full year pretax adjusted earnings of at least $6.9 billion and for the third quarter earnings seasonality to be consistent with prior years. Within Cigna Healthcare, we are raising our full year pretax adjusted earnings outlook to at least $4.55 billion and we expect the third quarter pretax adjusted earnings to be over 60% of the second half earnings. For the medical care ratio, our full year MCR guidance remains unchanged and we expect the third quarter MCR to be slightly above second quarter, consistent with historical seasonality.

Turning to our 2026 capital management position. Second quarter operating cash flow was in line with expectations and consistent with historical patterns, which is influenced by calendarization impacts that shift a portion of receivables into early July. We continue to expect our cash flow to be back half weighted, consistent with prior years. Our debt to capitalization ratio was 42.8% as of June 30, and we expect to end the year closer to our target of 40%. In the second quarter, we repurchased approximately 900,000 shares of common stock for approximately $250 million. We continue to view share repurchases as an attractive use of capital while maintaining a focus on debt paydown and disciplined capital management.

Now to recap. Our second quarter results reflect focused execution with both Evernorth and Cigna Healthcare, delivering pretax adjusted earnings above expectations while we continue to make progress on initiatives to support our long-term growth strategy. We are pleased with our performance in the first half of the year and are confident in our increased full year 2026 adjusted earnings per share outlook of at least $30.45. We look forward to our upcoming Investor Day in September, where we'll go deeper on our long-term strategy, growth opportunities and the outlook for Evernorth and Cigna Healthcare.

And with that, I'll turn you over to the operator for the Q&A portion of the call.

[Operator Instructions]

Our first question comes from Stephen Baxter with Wells Fargo.

I was wondering if you could maybe speak a little bit about how you'd expect the earnings growth progression within Evernorth to develop both for specialty and care and pharmacy benefits and how the pace of investments is impacting that.

Thanks, Steve. So we are really pleased with Specialty & Care's second quarter results, which exceeded our expectations. Now performance during the quarter was driven by continued strength in specialty utilization, faster-than-expected adoption of biosimilars and specialty generics, which improves operating efficiency. We saw improved operating efficiency and contributions from Shields. Notably, Specialty generic penetration exceeded 80% for newer products during the quarter. These therapies improve affordability for patients and support clients and contributed favorably to earnings performance.

So overall, we expect it to continue to perform well as we look through the back half of the year. We expect Specialty generics and biosimilars to be a meaningful tailwind, and we expect strong -- we expected strong penetration throughout the year and built that into our original full year guide. We experienced it earlier than expected. So the magnitude of the benefit we saw in the second quarter is not expected to repeat at the same level in the third and fourth quarters, but we still expect strong results as we look to the back half of the year for Specialty & Care.

Our next question comes from Lisa Gill with JPMorgan.

Brian, you made a comment that the PBM selling season was very strong. Can you maybe just do 2 things. One, can you talk about renewals and where your renewals are at? And two, can you size new business wins? And then thirdly, as we think about how important, how big your Specialty business is, can you talk about are there incremental opportunities within specialty? What did you see in this year's selling season specific to specialty? Are you seeing carve-outs? Or your winning more business? Is it just incremental business through the PBM contracting. Just want to better understand how you're thinking about the selling season.

Lisa, I appreciate the multifaceted nature of that question. So maybe I'll talk about the '27 selling season just more generally across the company and get to some of the specifics of your question on our Pharmacy Benefit Services and Specialty Businesses throughout that. As it relates to just common themes in the selling season, affordability continues to be the most pronounced problem across the health care space, and that's exacerbated certainly in the prescription drug space by the high unit prices for brand drugs. And then, of course, on the medical side, by the upward march of hospital prices, which has continued. And so those affordability pressures have led employers to consider alternate plan designs as well as financing solutions. Fortunately, we're well positioned to support employers and other buyers in those alternatives.

A second common theme we're seeing is the focus on customer experience, what we call personalization with employer and health plan clients increasingly looking for partners who will engage individuals with the right information at the right time in their preferred modality. And these themes are squarely where we're focused as an organization. So as it relates to the specifics on the growth platforms. Within our Evernorth Pharmacy Benefit Services business, we closed 2026 with over 97% retention. And the preliminary indicators for 2027 also suggest mid-90s or higher retention. So both of those 2026 and 2027 years are very consistent with historical norms.

And to your point, as I shared earlier, our 2027 new business performance is quite strong. Total new business already secured is above the prior two selling seasons combined. So a very strong '27 new business performance. And looking forward, our new rebate-free signature model is generating considerable interest from both existing clients and prospects as we look to scale it in 2028 and beyond. So this is good evidence that our clients see us as a multiyear thought partner as they prepare for future changes in their Pharmacy Benefit Programs.

In the Specialty & Care services platform, we continue to benefit there from secular tailwinds, as Ann was just referencing, which leads to more patients utilizing specialty drugs along with our Accredo Specialty Pharmacy being included as a network option and even more unaffiliated EVM offerings. We also continue to see strong growth in the hospital and health system space where our fee-based offerings from Verity from Care Path and some of the synergy we've been able to accomplish from our Shields Health Solutions investments are starting to pay off. So putting all those pieces together, our solutions continue to adapt to market needs. We're confident in the long-term durability of the Cigna group and pleased with the performance so far in the '27 season.

Our next question comes from A.J. Rice with UBS.

I might pivot over to the benefit side. I appreciate the prepared remarks comment about the surgery volumes. I was wondering, is the overall cost trend you're seeing in the commercial business consistent with what you thought high single digits, I think, is where it was pegged or is it what you're seeing in surgical enough to move the needle?

And then, I guess, your comment on GLP-1 mainly on the Evernorth side. Is that helping you on the commercial cost trend. And you're also referencing a risk adjustment benefit. I wondered if you could size how meaningful that was for you in the quarter.

A.J., I'll start on the first couple of components and, Ann, maybe you can pick up on a risk adjustment and anything I missed from the first 2 pieces of A.J.'s question. So as it relates to Cigna Healthcare, obviously, we're pleased with the strong performance in the second quarter despite a challenging and dynamic operating environment, and the strong performance was driven by slightly favorable medical cost experience in the quarter, which resulted in the MCR being slightly favorable to expectations.

Now to your point of absolute level, we continue to see high single-digit type cost trends. So persistently elevated cost trend levels, not a significant deceleration and no acceleration fortunately as well. So that's how I would encourage you to think about what's happening with the cost trend environment. And to Ann's point, we're seeing -- we saw a little bit of favorability in the outpatient side, but again not enough to call it a break in cost trends at this juncture. And our forward-looking assumptions continue to assume an elevated cost trend environment through 2026 and 2027.

On the GLP-1 side, as we were talking about in respect to Evernorth, we saw some deceleration in the growth rate of GLP-1 prescriptions in the second quarter, which puts some very modest downward pressure on the PBS financial picture in the second quarter. That was more than offset by the strength in our Specialty business, which led to overall Evernorth results being above expectations.

To your point, on the Cigna Healthcare portfolio, the very modest benefit from the standpoint of GLP-1 prescriptions being a little bit lighter. But keep in mind, in the Cigna Health care portfolio, we serve many smaller employers who did not cover GLP-1s for weight management. So we continue to only see 15% to 20% of the book covering that for weight management. So the overall financial impact there was fairly immaterial as you think about the pull-through in the Cigna Health care portfolio. Ann, can you address the risk adjustment question that A.J. asked.

Yes, sure. So A.J., the release of the 2025 final risk adjustment data and also the June weekly update for 2026. confirmed our risk adjustment position, so results were consistent with our expectations, and it wasn't a driver for the quarter.

Our next question comes from Charles Rhyee with TD Cowen.

Ann, I think you mentioned in pharmacy benefits or about biosimilars that it kind of benefits specialty and it was -- it sounds like there was a little bit of a headwind for pharmacy benefits. Is that a function of -- maybe you can talk about sort of the mechanics is that you get better margins as on the SP side, but maybe the impacts in terms of rebate dollars and GPOPs on the pharmacy benefit side. And then just real quickly, if you could comment on in Cigna Health care I know there's been a lot of concerns about IDR and maybe sort of talk about your exposure related to that and stop loss.

Charles, let me just provide a few opening thoughts here and Ann can get some of the details on both of those important questions that you raised. So first off, on the specialty generics and biosimilars. We're really pleased with the strong second quarter performance as we saw more rapid adoption of both biosimilars and specialty generics in the quarter. And Importantly, we're seeing this building momentum across America of biosimilars and specialty generics, powered forward particularly in the past couple of years as HUMIRA biosimilars become more mainstream. And really, we're still in the starting point of a multiyear wave with respect to more biosimilars, especially generics coming to market.

And importantly, these cost-effective prescription drug alternatives are all examples of putting our patients first in our strategy because they result in lower out-of-pocket costs as well as a better net price for the employer, the health plan or the government entity that's funding the drug underneath. So we're really pleased to see that.

On the Cigna Healthcare side, as I mentioned earlier, in A.J.'s question, we're pleased with the favorability we saw in the second quarter in aggregate for Cigna Healthcare relative to the IDR aspect of your question, we do support the overall strategic intent of consumer protection from surprise billing. However, we're seeing some clear abuses of the IDR vehicle in practice. So we're seeing right now the IDR mechanism has seen unsustainable volume levels, much of which is concentrated amongst a small number of providers. The vast majority of the settlements are favoring providers both in terms of the frequency of wins and losses as well as the result in payment amounts.

And all of this just further exacerbates the affordability challenges for employers and health plans who are ultimately required to pay these outsized settlement amounts. In fact, 2025 alone, the research that was published showed $15 billion health care spending across the industry was processed through the IDR mechanism. And we view much of that spending as wasteful or abusive. Now for us, specifically, the impact has been manageable within our Cigna Health care planning and pricing assumptions. So a little bit of color on each of those parts of your question.

Ann, maybe you can talk a little bit about the P&L geography, if you will, on the generics and biosimilars is there anything further you want to add on the Cigna Healthcare side?

Sure. So on the Specialty Generics and the adoption of that and how it sort of lands geography-wise, within the P&L as we see stronger adoption of biosimilars and specialty generics is the benefit for us overall in Evernorth from a margin perspective. It benefits the patients and our clients as well. But the economic shift from pharmacy benefit services to the Specialty & Care line. And there's also -- because drug costs are lower, you'll see a sort of not a proportional increase in the revenue line.

So overall, I'd say, overall net benefit to Evernorth as a whole, lower results in Pharmacy Benefit Services and higher results in Specialty & Care and sort of how it all comes together.

I think your last -- so I was just shifting over to the Stop Loss. I think your last question was there on Stop Loss you say that we're tracking in line with expectations. So it was not a variance driver in the second quarter. We've done a lot of work to enhance our analytics and clinical data to monitor early performance, and these indicators are tracking well.

I'll just give one example. We've seen stable frequency trends and high-cost payments across multiple attachment point levels. So these trends have developed consistent with both our expectations and in line with the levels that we observed last year. So all in all, we -- all of these indicators support our confidence in the Stop Loss book and our expectations for the full year.

Our next question comes from Justin Lake with Wolfe Research.

Just want to follow up on something you just talked about here. Your Specialty growth has been phenomenal in the first half of the year. Your guidance is intact for Evernorth overall. So it does feel like the PBM services side is maybe a little weaker. And -- so that was kind of the core of my question. It sounded like in your last answer, you were talking about the fact that there might be some geography or earnings shift because of biosimilars. So I was hoping maybe you can double-click on that a little bit. Is there any way to give us some proportionality or put some numbers around how that -- how much specialty earnings are being benefited by that and how much PBM earnings are being kind of offset?

Sure. Thanks for the question, Justin. Maybe I'll just start just by saying we're really pleased with overall Evernorth's second quarter performance, which came in slightly ahead of expectations. So there were pockets of outperformance in the quarter. We saw a faster penetration, like you said, for specialty generics and biosimilars and Specialty & Care and also some modestly lower-than-expected GLP-1 volume growth. So when you couple those together, it supports maintaining our current guidance rather than raising at the time.

As we look ahead at the back half of the year, we continue to expect specialty generics and biosimilars to be a meaningful tailwind. However, we came into the year, we expected strong penetration throughout the year, and we've built that into our original full year guide. So we experienced it earlier than expected. So the magnitude of the benefit that we saw in the second quarter is sort of not expected to repeat at the same level in the third and fourth quarters.

And so -- at the same time, within Pharmacy Benefit Services, we saw the moderation of GLP-1 growth rates that had a slight impact on the actual quarter, but we expect that dynamic to continue through the balance of the year. So when we look across Evernorth, we've got a couple of offsetting dynamics. PBS tracking modestly below our earlier assumptions due to the shift in economics. And the faster adoption of specialty generics and slightly lower GLP-1 volume growth, both Specialty & Care is performing above our expectations, driven by the continued strength in the specialty generics and biosimilars. So when we put that all together, we remain confident in the overall strength of the Evernorth business and in our prudent full year outlook.

Just to simplify this down a bit as you think about what happened in the second quarter versus the full year, we had strength in the second quarter above expectations for Evernorth. We're anticipating a little bit of modest downward pressure on the GLP-1 volumes for the back half of the year. So essentially, the outperformance in the second quarter is given back in the form of slightly lower GLP-1 volumes in the back half of the year. So that's how I encourage you to think about the overall segment. But importantly, the overall strength of our enterprise allowed us to raise adjusted EPS for the full year to at least $30.45 which we feel very good about heading into the third quarter here.

Our next question comes from Erin Wright with Morgan Stanley.

Great. And might be getting ahead of the Investor Day, but you're obviously taking a step back in the PBM with a PBS with the transition that you're making this year, but do you remain relatively flat in that business in 2027 and then grow 2% to 4% PBS long term? Is that the right kind of growth algorithm with durable margins in that 3% to 4%? And net-net, does that mean that you hit the low end of the 10% to 14% EPS growth in 2027?

And just as it relates to that PBS model transition, you spoke to the selling season, which, yes, is important, but it's also early. But there's other levels of recontracting here that are important, right, like in terms of the renegotiation process with pharma companies and pharmacy as well. I guess how is that part of the transition progressing relative to plan?

Erin, there's a few different aspects to your question. So let me talk first about the financial side, and then I'll pivot over into the status of our signature model build-out. So relative to where we are on '27 and the multiyear trajectory of PBS, obviously, we're only halfway through '26. So it's a bit early to provide formal guidance for '27. That said, at the enterprise level, our view for '27 continues to be consistent with our prior commentary to deliver against our 10% to 14% EPS algorithm. And we'll provide more detailed guidance as we typically do on our segments during our fourth quarter call.

As it relates to Signature and the status of where we are right now, first off, we're proud to lead the industry with our new Signature Pharmacy Benefits offering. As I mentioned earlier, affordability continues to be the #1 challenge facing patients, and that's particularly acute for high-cost branded prescriptions, which represents just 10% of all prescriptions in America, but some 90% of the drug spending.

And as we engage with all key stakeholders across the Pharmacy Benefits ecosystem, whether that's an individual employer or broker or drug manufacturers themselves, everyone acknowledges that the status quo is unsustainable. So the market feedback so far on our work there has been positive as these stakeholders learn more about the model. When you think about the Signature model, it's fully aligned with the requirements of the Consolidated Appropriations Act provisions, which will be effective in mid-2028. And with our Signature model, we took it even multiple steps further beyond that regulatory minimum in order to simplify pharmacy benefits for our stakeholders.

So for patients the price assured capability guarantees customers the lowest possible out-of-pocket cost. So whether that's through our negotiated price, their co-pay or a cash pay alternative for employers and other clients. We're seeing a lot of interest and appetite here because there are increasing fiduciary obligations, and they see the Signature model as a direct way of meeting those obligations and the model offers greater budget predictability through simple fee-based arrangements.

You also asked about drug manufacturers. We've been actively engaged in conversations there for months, starting with the larger ones. The conversation so far, positive and productive. Manufacturers know that lower prices for patients at the counter will ultimately result in greater satisfaction, better adherence, less need for copay assistance. You also asked about the network pharmacies. Our new reimbursement model of cost plus a dynamic dispensing fee will ensure that clinical complexity is properly reflected in what the pharmacies are ultimately paid.

So put all those pieces together, we're tracking well to scale our Signature offerings in 2028, and we'll have the Cigna Healthcare insured book as early adopters in 2027. And I shared the strong 2027 selling season as an early data point that our clients are seeing us as a multiyear thought partner that they prepare for all those future changes in their Pharmacy Benefit programs. And we're confident that ultimately, our Signature product will yield margins in that 4% range as you asked about, similar to what our legacy Pharmacy Benefit Solutions products were able to deliver.

So apologies for all the detail there, but hopefully, that hits the core of your question.

And next question comes from Kevin Fischbeck with Bank of America.

Great. Maybe if I sneak in two just real quick. What kind of free cash flow are you expecting in the back half of the year? I think you've talked about that accelerating? Just trying to figure out what's available for capital deployment. But then also kind of maybe building on the Signature commentary. Any update on just how the transition expenses are coming in, you still feel good about those numbers and then those numbers going away, starting in '28 and then by 29%.

And I wasn't sure I mean, I think most of your comments about Signature and reception to Signature have been on the PBM side of things. And I understand that the rebate aspect, it might be the biggest component of signature so it doesn't really apply to the risk customers, but there are other aspects to it as far as you mentioned the point-of-sale rebates and things like that. How are those things being received by your risk customers as you head into 2027? Any feedback there?

So thanks for the question, Kevin. I'll start on the first 2 parts of the question related to cash flow and transition expenses. So as you know, our cash flow come around from quarter-to-quarter, largely because of the timing of supply chain receivables and payables. Second quarter is typically lighter than other quarters, primarily because of calendarization shift -- shifts a portion of receivable payments into early July. So that timing, if you're looking at our second quarter or first half cash flows, that timing affected the numbers that you see, but our full year outlook remains unchanged. We continue to expect operating free cash flow of approximately $9 billion and that to be mostly back half weighted.

Specifically with respect to your question on the transition expenses, we came into the year with an expectation of continued investment in Signature. We are tracking exactly to what we expected to spend this year. We expect to spend similar levels in '27. And then we'll continue -- obviously, continue to invest in the business over time at the right level. But the levels of investments should ramp down over time.

And the final piece of your question in terms of market receptivity from our employer clients. It's -- obviously, the impact of moving into Signature model will vary client to client. So those that have high deductible plans tend to see the most amount of change relative to where they are today. Those that are in co-pay plans today tend to have minimal impact relative to what it does to their financials, what it does to patient by patient cost sharing dynamics. So the impact varies by client.

For our risk book thus far, Kevin, it's actually very smooth because if you think about the way risk business is priced, everything is in there from the standpoint of there's one price and as a result of that, we consult client by client with any plan design changes that they may want to consider. But so far so good on the risk book of business.

In 2028, we'll scale the model more broadly. We'll have a lot more self-funded business in this model. And as I was making reference to earlier, that's where we see particularly the increase in demands on fiduciary obligations being important and a lot of our clients interested to move in a simple fee-based transparent model that we've introduced.

Our next question comes from Scott Fidel with Goldman Sachs.

Interested if just with the planned exit from the exchange business and how that's going to free up some capital and also just some of the resources -- just looking at the listing on the health care business, are there other end markets or existing lines of business that is sort of thinking about emphasizing more or looking to potentially sort of roll out additional offerings. And clearly, middle market and select have been sort of the long-term historical focus, I'm sure that you're going to continue to do that. But maybe national accounts or large group, curious around how you're thinking about maybe redeploying resources of capital into them as you remove the exchange capital and resources off of the portfolio.

Scott, I'll start and then Ann can pick up on the implications of the individual exchange sunsetting that will happen at the end of this calendar year. Overall, we really like our positioning in the Cigna Healthcare business and do not feel any compelling need to enter different end markets at this juncture. And a lot of that comes back to the discipline we've had around portfolio shaping and being really focused as to where we feel we have the differential right to win and not trying to be all things to all people in terms of serving all different end markets where we maybe don't have the specialization or the expertise. So we'll continue to invest in our U.S. employer business in the way that we have for many years, and we continue to see more headroom for growth, particularly in the under 500 Select segment, where we've continue to grow even in a very complex dynamic operating environment.

See, customers are up 5% year-over-year. and we couple that with our expertise in risk transfer with our Stop Loss offerings where we're tracking for over $8 billion of premiums this year. So we continue to really like the U.S. employer space.

Now along with that, there are a variety of additional products that can attach. So things like more and more supplemental health benefits or voluntary benefits as employers look for opportunities for affordability improvement. So we see more and more benefits potentially going to a voluntary chassis over time. So we're excited about that opportunity. We continue to look to scale our International Health business, which has been while a small part of the overall company, a very strong source of performance over a multiyear period.

So do you not feel compelled to get into other elements of the health plan space at this point. We're quite pleased with what we have in terms of the current franchise. Ann, do you want to pick up on the individual exchange exit implications?

Yes, sure. So there are 2 key factors to consider regarding the impact of the ACA exchange exit when you're thinking about our 2027 results. So as a reminder, for this year, we're coming into the year, we expected margins in the business to be positive, but below target levels. Year-to-date, we're tracking consistently with that expectation, sort of right on point. So that's a consideration as you look into '27.

Second, we do expect some stranded overhead as we exit the business. We're continuing to evaluate, manage through this impact. We'll provide further details on that as we close out the year. And then lastly, to your point on capital release, There'll be a modest capital release, but nothing of significance to note with respect to that.

Our next question comes from Jason Cassorla with Guggenheim.

Great. Maybe just on the medical side of Specialty & Care. You've had the investment in shields for almost a year now. You flagged opportunities to partner with hospitals and health systems. I was just hoping maybe you could delve into that a little bit more. It sounds like you're seeing strong growth there. But I guess where are you seeing in terms of your solutions resonating if the momentum that you're seeing kind of gives you greater confidence in penetrating that market. I guess, just a bit more on the trends and expectations within the hospital and health system opportunity would be very helpful.

Jason. So I'll take that question as it relates to the -- we call Health System Services business within Specialty & Care Services, and we call it Health System Services because it's both hospitals and health systems and really build on the expertise that we've amassed over a multiyear period in the Specialty pharmacy space. So if you think about specialty pharmacy space more broadly, it's approaching a $500 billion total addressable market with high single-digit secular growth moving forward. So one of the few subsegments of the U.S. health care system with such strong secular growth, which is why we're so excited about our existing position as well as the expanding capabilities we're developing in the hospital and health system space.

Now within that $500 billion -- nearly $500 billion addressable market, approximately 60% of that is what we describe as direct-to-patient where we've already achieved an industry leadership role in this clinically intensive business. So here, you can think of primarily through our Accredo Specialty Pharmacy. And then the remaining 40% of that $500 billion addressable market is provider administered drugs where we've historically had a relatively small position. So this is where we've been making investments with our acquisition of Carepath, with our Verity capabilities and where Shields Health Solutions is focused. So Shields is specifically focused on providing management services to health systems to operate their own specialty pharmacies, and Shields is the clear leader in the management services space. They serve over 80 sizable health systems, representing more than 1,000 hospitals across 50 states.

You can think of our future growth opportunities in this space really in 3 different categories. One is the natural secular growth of the market as specialty drugs continue to grow. Two, the percentage of health systems who hire a management company today is relatively small, which offers a natural growth opportunity for us as this market matures. And three, there are some mutual value creation opportunities between Shields and Evernorth through our respective client relationships and the broader suite of combined capabilities that we have, which could result in expanded solutions for those clients. So this is an area we're going to continue to invest in. We're excited about the opportunities as margins continue to compress for hospitals and health systems that are working increasingly at their own in-house pharmacies and their specialty drug capabilities, and we are there to help them to support them on that journey. So I appreciate the question.

Our last question comes from Sarah James with Cantor Fitzgerald.

Cigna ended employee coverage of GLP-1 for Wegovy and Zepbound on July 1, citing rising availability and new options. Are you seeing that same sort of driver being reflected in your midyear updates or your early 2027 renewal conversations? Or has there been more pushback just on direct cost rather than the new oral entrants. And then how does that mix of drivers interact with how you see growth trends for EnCircle going forward?

Sarah, I'll attempt to hit the different components there. If I miss anything, please let me know. So starting with the GLP-1 coverage within our employee health plan. Just like other large employers in the U.S. were faced with constant trade-off decisions related to the comprehensiveness of our employee benefit programs versus the competitiveness of our products and solutions in the market and the associated profitability of those. So we did make the difficult decision during 2026 to discontinue financial support for GLP-1 drugs for weight management within our own employee health plan. And that coincides with broader availability of GLP-1 options that are now available in the market for individuals using the drugs for weight management, inclusive of the orals and tablets that you made reference to.

We are offering a supplemental discount program to those employees who wish to pay out of pocket, and our clinical programs are available to support them. We'll continue to cover GLP-1s for diabetes within our own plan.

Now the decision that we made in our employee benefit plan is driven by the exact same set of challenges that many of our clients are facing, specifically where the net cost of the drug is straining the overall affordability of the plan. Now of course, we'll continue to monitor the situation carefully and should drive manufacturers decide to meaningfully discount the net prices they offer. We may revisit this in the future. Across our broader client base, we're seeing some of those same decisions being made and made reference to you earlier, a slight downtick in the percentage of our employers in Evernorth that are covering GLP-1s for weight management, and that produces a modest headwind to our 2026 results, which fortunately, it was overwhelmed or was more than offset by the strength in specialty in the second quarter. And so overall, Evernorth results continue to deliver.

As it relates to the GLP-1 coverage decision and the implications for our support programs, we continue to offer a variety of financing solutions for employers that range from fully covering the cost of the GLP-1 drugs to covering a portion of the cost to offering it on more of a sponsored or voluntary basis. So this space will certainly continue to evolve in the future. Our Circle program continues to be very effective for those employers who do cover it for weight management. But we expect that this is going to continue to be an area of debate tension for employers in terms of funding for these drugs going forward. So I appreciate the question. Let me know if there's any elements in there that I didn't cover.

I will now turn the call back over to Brian Evanko for closing remarks.

Thanks for your questions and for your time today. With our momentum, we're confident that we'll deliver on our increased adjusted EPS outlook of at least $30.45 for 2026. We look forward to hosting our Investor Day this fall, where we'll discuss advancements in our growth strategy and in each of our businesses. But before we close, I do want to recognize and express appreciation for our coworkers around the world. It's their continued focus and dedication that supports our ability to deliver on our commitments for those we serve and for our shareholders. We're proud of what we've achieved and are excited about the opportunities ahead. Thanks for joining. Hope you have a great day.

Ladies and gentlemen, this concludes The Cigna Group's Second Quarter 2026 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) 405-7290 or (203) 369-0603. There is no passcode required for this replay. Thank you for participating. We will now disconnect.

All right, great. I want to thank everyone for joining us. It's my pleasure to be hosting this conference with The Cigna Group. Today we have Brian Evanko, who is the incoming CEO of the company. And we also have Ralph Giacobbe and Jeff Rook in the audience as well. But -- so maybe just jump right into Q&A, if that's okay.

Sure.

All right. So I mean, I guess, you're one of the major overhangs it seems for the stock right now is just on the PBM business. There's a big transition going through from your model from the rebate-based model into this new signature model, rebate-free model. Can you talk a little bit about why you did it, what you're going to expect to get from it and how we should think about the earnings impact as you transition?

Sure, Kevin, and thanks to you and Bank of America for hosting us this conference. We appreciate that. Maybe I'll give you a little bit of the background for how we got to the new signature model, and then I'll address some of the specific questions you were asking about.

If you think about the challenges with pharmacy benefits in America, there's a few words that bubble to the top, affordability, personalization, transparency, predictability. Each of those represent opportunities for the industry to perform better on behalf of patients, plan sponsors like employers and all their family members.

And so we stepped into that void and said, you know what, where we see the world going is in the future, a simpler, more transparent, more personally relevant, more affordable for patients, a world without rebates, but instead having simple upfront discounts, and the ability for the plan sponsor to have more budget predictability through a simple fee-based delinked pricing structure.

And so that essentially provided the background for where we're driving with the signature model. And we think the whole industry will go there eventually in time. We were proud to lead the industry by announcing this in October. And subsequent to that, as you saw some of the legislative activity, you saw some of the FTC activity, it all very much aligns with that strategic direction.

So again, we see the industry heading there eventually. It's just a matter of who goes first, who goes second, who goes third. So we were proud to lead the industry. Importantly, though, this is a fundamentally different model than the current rebate-oriented architecture that exists. So this is not 100% rebate pass-through, which we can do today, which we do today. This is not point-of-sale rebates, which we can do today, which we do today for some clients. This is a no rebate world that's all predicated on upfront discounts that we negotiate with manufacturers.

But to bring that to life, it's actually a pretty heavy lift. We have to go out and recontract with all the pharma manufacturers. We have to go out and recontract our pharmacy network with all the retail pharmacies, independent pharmacists, et cetera. We have to go out and recontract all of our client contracts. And all that takes time, energy, investment, technology spend, legal spend in order to bring it to life.

So '26 and '27 will be transitional years where we're making those investments before the signature model starts to scale in '28, and we expect at least half of our Evernorth Pharmacy Benefit Services members will be in that model by the end of 2028. That will be our standard offering in the future. We'll continue to allow the current legacy models to exist to the extent that a client is not ready to go into the new signature model. But '26 and '27 will be transitional years with that spending. '28, you'll start to see those costs dissipate.

And then in the longer run, we would expect the profitability of our new model will be very comparable to the legacy model once that's fully scaled. So that's a bit of the picture that's in front of us. But importantly, it starts with those principles of affordability, personalization, transparency, predictability, and we see the world going in this direction because there are too many instances today, where we see individuals not fill their prescription due to than being in a high deductible plan and the lift price is a barrier. And so this allows us to step over all those challenges and see the future.

Okay. So maybe just drill into that comment about the margins because -- so longer term, does that mean 2029? Or does it mean 2030? Like how long does it take to get the PBM margin to be similar to where it is today or historically?

Yes. The way I would encourage you to think about the margin profile for our pharmacy benefit service business is in 2 categories. One, we have 3 very large clients that we serve, Centene, Prime Therapeutics and the Department of Defense. We proactively renewed them and extended the duration of the contracts last year.

And as a result of that, we have a more predictable set of clients with those 3 and a more predictable earnings stream, but it's at a lower average profit level than the book average. And as a result of that, you can think of those as a bit of a separate cohort from all other. So that's about $65 billion of pharmacy benefit revenue. It's about $90 billion in total if you include specialty pharmacy and some of the other components.

The other component of the book, we would expect to run, call it, 4% profit margins. And to your point of when, certainly by '29, we would expect the signature model, the legacy model will be in that 4% profit margin zone for that other portion of the book, which is, if you go back in time, approximately where the industry has run, where the large competitors have run, and we believe is commensurate for the value creation as well as the risk that we absorb in those relationships.

Yes. And you guys have talked about this rebate-free model. It seems like -- your competitors have also announced new models that are more of the 100% rebate pass-through. So like what do you believe that the rebate-free model is solving for that maybe the rebate pass-through model isn't?

Yes. So to your point, we offer rebate pass-through models today, 100%. Some want us to retain portions of that depending on the client relationship. And that will continue to be available for clients in the future, if they're not prepared to go to the signature model, if they're unable to, if they have collective bargaining agreements, that sort of a thing.

So we'll have 2 offerings available in the future, but the standard will be the signature model. One of the big differences is the predictability and the budgeting for the plan sponsor. So in the rebate model, there's still variability in what happens with the flow of funds relative to the settlement of the upfront rebates, if it's a point of sale or the ability to know downstream because rebates are post-utilization true-ups.

Exactly what happens there. This provides more predictability because you know the upfront net cost. It's been negotiated already with the manufacturers. And importantly, for the patients, the Price Assure Capability, which we have embedded in the signature model, we have a version of it available today actually, but in the -- it's going to be a really central part of the signature model, guarantees patients the lowest possible out-of-pocket, whether it's the price we've negotiated from the manufacturer, if it's their co-pay or if it's a cash pay option.

And if it is a cash pay option, it will apply to their deductible. So that capability is a really important part underneath the signature model. But I come back to your core of your question, the predictability is even greater in this model versus in a rebate-oriented model.

Okay. And so just to be clear then about how this works. So if you're guaranteeing a price to a customer, that is the price that you have contracted with the pharmaceutical manufacturers. So it's not a situation of you're taking risk on the price that if the manufacturer raises price midyear, that's separate from your negotiation. And so it's all passed through, but it's set in advance rather than post fact.

Correct. We've negotiated the net price with the manufacturers. So we're going through all the manufacturer recontracting as we speak.

Okay. And so then what do you think are the competitive implications of this model? I mean when I think about this, it feels analogous to the ASO model, where you kind of have transparent unit costs and usually the companies with the lowest unit cost win. So is that what you would expect that the largest players with the best unit costs are just going to win when the model moves in this direction?

I appreciate that question. If you step back and think of what are the value creators for any PBM or for us, our pharmacy benefit service business, there's really 3 primary ones, one being unit cost. So the ability to procure better unit cost than an employer health plan government entity could do on their own. So to your point of where you get some buying power advantages, certainly on the unit cost component in terms of, if we bring more volume to a manufacturer, generally, we can get a better net price.

The second area is our clinical programs. So oftentimes, these are overlooked in the pharmacy benefit space. But importantly, making sure patients adhere to their treatment protocols, in some cases, we take risk or we have value-based arrangements with manufacturers like our SafeGuardRx program or our EnCircleRx program.

Those clinical programs are another reason why we are hired by employers and health plans and government entities. And then the third one is all the benefits administration that we do, the formulary management, the network design, all of that work we're doing on behalf. So those are the 3 reasons why we create value, why we're hired to provide services in the pharmacy benefit services space.

To your point, moving to a rebate-free simpler fee-based model, it makes that first component, the unit cost much more easy to see and compare. And so that should, over time, provide advantages to those who have better unit cost structure. Today, it's often difficult to do an apples-to-apples comparison with the different models that are in place.

So we like that about the model because being the largest pharmacy benefit services player in the industry, we have great unit costs. So we like the competitive opportunity there. All that said, our longer-term EPS growth algorithms, our longer-term expectations for this business are not predicated on taking market share. So we are not betting on that. So to the extent that happens, that's upside to our long-term outlook.

Great. Can you talk a little bit about then the 2027 selling season. You've got this other option, which isn't available yet, but you're talking to people about it. So I guess what's the reception to the new model? And then how is the selling season on the old model going for '27?

Yes. To your point, the new model will scale in '28. We'll have our fully insured Cigna Healthcare customers moved into it in '27 because they essentially don't go through a buying process for the pharmacy benefit business. They just -- they have it as part of their all-in pricing.

So the real feedback we'll get relative to bidding will happen starting in the fourth quarter of this year or '28 selling cycle since the buying process is long, particularly for large employers and health plans. So we'll start to get some real feedback in the fourth quarter of this year as it relates to the '28 competitiveness of the signature model. 2 weeks ago, we had many of our large clients together, and we got some great real-time feedback, which has helped us to make course corrections if needed along the way, but it's not yet in the context of a selling cycle. It's more in the context of directionally, here's where we're intending to go.

But there's a lot of interest and appetite for this because employers know the market needs to change. They know that the pharmacy benefit model of the past isn't the right model for the future. There's just too many examples of patients being exposed to the high list prices, when they're in their high deductible plans and they're in the deductible phase. There's too many instances of that breakage.

So the clients know the world needs to change. It's more a matter of how quickly they get there. Now to your question on the '27 selling cycle, so far in pharmacy benefit services, we're off to a really good start. So we have more new clients, more new business measured by scripts, measured by lives at this juncture than we did last year or the year before at this point in the respective selling cycle. So we're off to a good start as it relates to '27.

To your point, it's our legacy model with evolution as opposed to the signature model for '27. And retention looks to be tracking in line with historical norms to or mid-90s or higher retention for the '27 selling cycle in the pharmacy benefit services business.

Okay. And then I think one of the other questions that we get from people about concern around the PBM involves the recontracting that you mentioned in the largest 3 contracts. I think people saw, okay, you recontract your top 3 contracts. Why not the next 3 largest contracts? Like is there now a race at the bottom as the market got to be more competitive? So how do you respond to that?

Yes. The 3 largest contracts, which each of them are very unique and bespoke and have specific requirements that only a very small number of companies in the world can actually meet those requirements have dynamics that I don't believe are indicative of the broader market.

So to your -- the core of your question, we do not see pricing dynamics that would lead to margins being cut at scale across the pharmacy benefit space. The '27 selling cycle coming back to that question, has underscored that. There appears to be good pricing discipline in the market right now across the pharmacy benefit space, which is why we believe that 4% margin profile is a durable level over the long run for the industry and for our book of business with the exception of those 3 large clients.

Each of the 3 large clients that have their own kind of unique requirements. And when we did the recontracting, we were able to extend the durations. In some instances, we actually derisked the nature of the contracts to make them more fee-based, more service-oriented in exchange for a lower expected return, which is one of the reasons our '25 to '26 earnings in pharmacy benefits are actually decreasing, which is driven predominantly by those 3 large contracts being renegotiated.

Okay. That's helpful. And then I guess maybe just last question on the PBM. I think sometimes people think that the PBM needs to grow fast, but your long-term growth algorithm was 2% to 4% growth. And so I guess, old model, new model, 2% to 4% growth, that's the same outlook as well.

At this juncture, and we'll have a formal refresh of all of our growth expectations in our Investor Day in September that we're intending to hold. But at this juncture, that looks like a very reasonable expectation, 2% to 4%. And if you kind of break that apart, just natural growth in terms of prescriptions per person tends to be low single digits, maybe 1% to 2% per year.

And then on top of that, we'll have an inflationary component in the fee-based compensation that we'll receive from employers in the signature model. So 2% to 4% long-term expectation feels very achievable. And again, it's not predicated on any market share gains. So that would all be icing on the cake to the extent we did gain any share in the future.

Great. Now let's move to a little bit more exciting part of the business, the specialty business. I guess, how do you think about the underpinning of that business? I mean we've had some biosimilars recently. There's a lot of drugs coming through. So how do we think about the pace and timing of the growth of that business?

Yes. The specialty business for us has been a great part of the portfolio the last several years. And over time, this has been the outsized growth component of the company. So right now, it's about 35% of the company's total income. It wasn't that long ago that number was 20% to 25% if you go back just 4 years. So as a percentage of the total, it's grown very quickly. And part of that is the strong secular growth in the space, which you've covered nicely in your research as well, Kevin.

This addressable market in total is now approaching $500 billion, the total addressable for specialty. So you kind of step back, that's larger than the individual Medicare Advantage market, right? If you just kind of do a -- I'm comparing apples and oranges here, but in terms of total addressable market size, it's actually quite large and growing.

So secular growth in this space, 7%, 8% over time, which has been powered by all the drug innovation of biopharma as well as some of the larger manufacturers. And increasingly, specialty drugs are being used as a first line of defense by more prescribers. So now 4% to 5% of all Americans take a specialty drug.

And again, it wasn't that long ago, that number was 2% of all Americans. So more and more people are taking these high-cost clinically intensive specialty drugs. We have a great leadership position in this business with Accredo, which is our specialty pharmacy. And then we've been adding capabilities around that to further expand our presence in the specialty space.

And so we've seen HUMIRA and STELARA come into any other drugs that you're kind of keeping an eye on as kind of like the next big thing for biosimilar?

Yes. HUMIRA and STELARA have been great examples of a win-win here for society, for patients, for companies like ourselves and for the plan sponsors who are funding the benefits, right? Because HUMIRA was the largest, which finally biosimilars were available in '24.

So we had a $0 patient out-of-pocket for that, which again, great affordability proposition for the patient. The net cost came way down for the employer, the plan sponsor relative to the branded HUMIRA. And then we were able to make the same or more per prescription with our model. So that was a great example of affordability for the benefit of patients.

STELARA last year was introduced with a $0 patient out-of-pocket as well in the second quarter of '25, and we've seen good uptake thus far in terms of the percentage of eligible patients who have moved into a biosimilar for STELARA, another one of those examples of a win-win.

This year, although not a biosimilar, generic Revlimid is now available at a much greater scale. So in the past, supply constraints made it much less available. That's going to be another example of affordability benefits, but also one where we get the benefit within our specialty business. And then in the future, there's a few smaller ones on the Horizon like Prolia and Eylea.

And then you've got KEYTRUDA, which is an oncology injectable, which in '28 or '29, that will have biosimilar competition as well. So each of those are opportunities, and it's a bit of a building wave of all the drug innovation and the benefits of generics and biosimilars making their way through, which should improve affordability, but also allow companies like us to thrive as a result of that.

I think that sometimes we kind of think of specialty as like one thing, but you've been investing in specialty the last few years. Can you talk a little bit about where you've been strong historically, what you've been adding to that portfolio, if there's any other white space that you kind of look at as saying there's an opportunity.

Sure, sure. Yes. So the specialty space, that addressable market I made reference to is approaching $500 billion. You can think of it as about 60% patient administered. So it could be orals, it could be injectables, but the patient is essentially administering the drug themselves, right, in their home, that sort of a thing. And then the other 40% is provider administered.

So this could be -- you go into the doctor's office for your drug to be infused or injected or other types of ways in which it's adjudicated. So 60% patient, 40% provider administered. We've historically been very strong in the 60%, the patient administered. So our Accredo capabilities, we're one of the 2 largest specialty pharmacies in the world pointed at that.

The 40% that's provider administered, we've been a little bit less present historically. We have a distribution capability called CuraScript, where we distribute specialty drugs to providers. That's a great business for us, been growing double digits for many years. But we've been adding to the portfolio, to your question, in recent years, capabilities that allow us to serve that provider-administered market differently.

So we acquired a company called Carepath, which assists with health -- our health system and hospital infusion services. And we made an investment, a strategic investment, a sizable one last year in Shields. And Shields provides essentially clinical coordination, inventory management and consulting services, for lack of a better term, to health systems and hospitals who run their own in-house specialty pharmacies to help them manage that profit pool more effectively.

So we continue to bulk up in that area. But specialty in aggregate, when you put an umbrella across all of this, we see as an 8% to 11% annual growth engine for the company, riding the secular growth tailwinds plus our own company-specific capabilities.

Are there other areas that you still don't really operate in that you need to add capabilities?

If there were any that I would call out, they'd be more certain conditions where we have some opportunity to strengthen. So oncology is an example of one where we actually have less of a meaningful presence today in the oncology space than some others.

But the capabilities we've been building over time and investing in give us a great overall platform here. So there's not a significant huge gap there. It's more some of the conditions where we can strengthen ourselves.

Yes. I guess when we think about regulatory risk, the new model, at least to us and the market doesn't 100% agree, it doesn't seem like. But typically the new model is derisking the PBM side of things pretty dramatically. The growth is in the specialty business. When we think about the regulatory risk and political risk on the specialty business, I mean, I guess 340B comes to mind. Is there -- help us think about your 340B exposure? And if there's anything else that you kind of see on the horizon as issues that you might have to manage...

Sure, sure. And the specialty business in addition to being a great growth engine is also -- it's a really important part of American Healthcare because every single person we serve in the specialty business is clinically complicated and taking high-cost prescription drugs. So it's a little bit different than other parts of our company where sometimes we have people that don't utilize health care.

In this, every single person we serve utilizes health care in an intensive way. So as a result of that, by definition, they need companies like us to be there for them. So when you think about regulatory risk, whether that's federal or state, specialty tends to have a little bit less of it just for that reason because you have such a reliance on the services we provide, the clinical support the engagement and many of our nurses are known on a first name basis by the patients that they serve, right?

We have 600 home infusion nurses they go to people's homes and help them infuse drugs. So for those reasons, a little bit less easy to scrutinize, if you will, it's more difficult to scrutinize because of the services we provide. All that said, we do provide services to the 340B participants. We serve as a contract pharmacy in Accredo, not to a great degree, but we do have contract pharmacies in Accredo. And then we provide services to the health systems and hospitals we were talking about earlier to help them manage 340B capabilities.

Overall, it's a relatively small part of the overall earnings for Evernorth and an even smaller part of the total Cigna Group, but it is a set of services we provide. We do believe the 340B program has an important purpose in American health care. And even if there were adjustments to it, we view that as certainly something we would be able to navigate through without a significant point of pressure, for example, to the company.

And the other dynamic, obviously, in this space is some of the state-based legislation working their way through on companies that own PBMs and specialty pharmacies. So we're using data, using facts, engaging constructively as much as we possibly can to show that the value creation is there for integrated care models, and we'll continue to fight those misguided bills that are working their way through some states.

All right. Great. And then maybe we move to Cigna Healthcare then. Q1 seems like utilization looks relatively modest, but skewed by weather, by flu, by all these things. I guess, how do you think about your visibility into how Q1 actually played out? Any additional color on like how April has gone?

Yes, Cigna Healthcare off to a good start this year. So we were ahead of expectations in the first quarter, driven by the medical care ratio coming in a bit favorable. And really, the drivers of that, we had a little bit of weather-related care deferral. We had a little bit of favorability in respiratory. And then we had some timing dynamics with our exchange business where we had more bronze in 2026 than we had anticipated we would have, and that has more of a steeper slope, if you will, on MCR seasonality, as you well know.

So all of that contributed to the outperformance in the first quarter. Some of that was timing, though, which we expect will reverse over the balance of the year. So we did increase the guidance for Cigna Healthcare by $25 million for the year, which contributed to the EPS raise that we had in the first quarter release. So far, so good for April. So not really a lot to report in terms of variability compared to our outlook.

So things are broadly tracking to expectations across both Cigna Healthcare and Evernorth. We continue to expect cost trends to remain elevated. So not accelerating from where they are, but elevated and persistently elevated. So our pricing, our planning continues to assume that for the balance of '26 and as we head into '27.

Okay. And then you guys are the only kind of pure-play employer-focused managed care company. So like why is -- why have you chosen that as the place to be?

So you're right, in Cigna Healthcare and Cigna Healthcare is about 40% of the company's income today. The lion's share of that is U.S. employer -- employer-sponsored business. And we've proven, if you go back over long periods of time, we've been able to grow over and above market rates. So by -- depending on what time frame you use, the market has grown 0% to 1% in terms of lives in the employer-sponsored space over a long period of time.

We've been able to grow particularly at the lower end of the employer market, what we call our Select segment, 50 to 500 at rates of growth meaningfully higher than that. So mid-single digit, in some cases, high single-digit rates of growth in that space. And really for us, that comes back to focus. So we've concluded we can't be all things to all people. We're not going to be able to be effective by spreading our bets across too many different end markets, whether that's in Cigna Healthcare, whether that's across the company in aggregate.

And we feel like we're really good at serving employers in Cigna Healthcare. So one of the reasons we sold our Medicare business last year, one of the reasons we stayed out of Medicaid is we don't believe we have the expertise to run that business as effectively as others, and we don't see a path for it to scale to be a meaningful part of the Cigna Group franchise.

And we've got great growth opportunities in specialties. We just talked about, continued growth opportunities in Cigna Healthcare in the Select segment and this opportunity to transform our pharmacy benefits model, while continuing to deliver for clients today. So that's really where we're focused right now.

Of course, we'll continue to evaluate those choices being out of the government business indefinitely is a big decision for the company to make. But for the current point in time, we're quite pleased with the portfolio composition and don't feel compelled to make any meaningful adjustments.

Okay. And then on the -- in the commercial book, there was the issue around stop-loss in 2024. So can you talk about how that repricing has gone and where we are on that?

Sure, sure. And for those not familiar with our stop-loss business is part of the Cigna Healthcare product suite for those employers who self-fund benefits, many of them will purchase risk protection on top of that. It could be individual stop-loss for an individual claimant that exceeds a certain threshold or it could be aggregate stop-loss where the employer says, I want a cap on my total budget outlay.

And so it's a great business for us over the long run in terms of the risk/reward trade-off. So we have about $8 billion of annual premium in the stop-loss book specifically, we're the largest underwriter in the world of stop-loss. All of the business that we do is integrated. So we don't do carve-out stop-loss, where we quote only the stop-loss. We only do integrated where we have the underlying medical and put the stop-loss around that.

To your point, '24 was a difficult year for us where claim costs exceeded our expectations rather meaningfully that year. '25 was a year where -- by the time '24 emerged, we were not able to reprice enough of '25. So '25 was a bit of a cutover year or transitional year. '26, we've been able to get sizable price increases. And one of the things I've been really pleased with is the retention of our clients despite those higher than historical price increases that have been necessary in the stop-loss book.

And then '27 will be the final year of the margin recovery on our stop-loss portfolio. But '26 off to a good start. Our guide reflects those dynamics. In '27, we'll complete the stop-loss repricing.

Yes. And it was like 2/3 this year, 1/3 next year. That was the...

Roughly, that's the right dimensioning generally.

All right. And then everyone seems to be talking about AI. I would love to kind of hear your views about AI, where you think the biggest opportunity is across your 3 businesses? And then is there anything people are getting too excited about with AI over their skis on?

Our belief at the Cigna Group is that data, advanced analytics and AI are a critical unlock for the health care system over the long run. So we do not believe it's overhyped in terms of the opportunities in health care. I can't speak to other industries, but certainly in health care, we believe that this is a critical part of driving more affordable, more personalized solutions in the future for customers and clients.

There's a few ways I'd just point to that we're using it already, and then there's some other frontiers. We've been able to take meaningful costs out of the back-office functions. So I shared a data point in our earnings release. Calls -- inbound calls per customer are down 20% in 2 years in our Cigna Healthcare book of business, and they're down 25% in our pharmacy benefit services business.

So that's a function of more and more digital engagement upstream for customers. And when customers do call in better first call resolution because we have AI tools available to our customer service representatives as they're engaging with patients. So that's an example in the back office of what we've done. Then there's a whole category of risk prediction.

So using all of the data that we exist that we have under the Cigna Group umbrella, we've been able to take the models historically, which were constructed by data scientists and actuaries and turbocharge those with AI capabilities. So we've gotten much more accurate risk prediction of who will be a high-cost claimant within our Cigna Healthcare book of business, which helps us with our stop-loss business we were just talking about. And it helps us to mobilize our clinical teams to engage earlier with those patients to help with their treatment protocols and their care journeys.

And we found that, that saved for the patients that engage $2,000 per year just as a function of that. So that's an example of risk prediction pointed at the affordability challenge. And then there's a whole set of use cases we're exploring in the customer experience domain to help reduce some of the fragmentation of patient journeys, whether that's the Cigna Healthcare AI virtual assistant that we launched last year, whether that's capabilities that we're putting into our call centers where instead of having an IVR phone tree, now you have a responsive AI agent engagement.

Those are the types of enhancements to the customer experience that we think AI will really help to turbocharge. So this is an area where we seek to lead. We're putting a lot of capital behind this. We're putting a lot of people behind this, and we think it's a critical unlock for the system at large.

All right. Great. I think that's all we have time for. Thank you very much.

Thank you, Kevin. Appreciate the time.

Ladies and gentlemen, thank you for standing by for The Cigna Group's First Quarter 2026 Results Review. [Operator Instructions] As a reminder, ladies and gentlemen, this conference, including the Q&A session, is being recorded. We'll begin by turning the conference over to Ralph Giacobbe. Please go ahead.

Great. Thanks. Good morning, everyone. Thanks 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, The Cigna Group's Chairman and Chief Executive Officer; Brian Evanko, President and Chief Operating Officer; and Ann Dennison, Chief Financial Officer. In our remarks today, David, Brian and Ann will cover a number of topics, including our first quarter 2026 financial results and our financial outlook for 2026. Following their prepared remarks, David, Brian and Ann will be available for Q&A.

As noted in our earnings release, when describing our financial results, we use certain financial measures, including adjusted income from operations, and adjusted revenues, which are not determined in accordance with accounting principles generally accepted in the United States, otherwise known as GAAP. A reconciliation of these measures to the most 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 the cignagroup.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 2026 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 to today's earnings release and in our most recent reports filed with the SEC.

Regarding our results in the first quarter, we recorded after-tax special items charges of $322 million or $1.22 per share. Details of the special items are included in our quarterly financial supplement. Additionally, please note that when we make prospective comments regarding financial performance, including our full year 2026 outlook, we will do so on a basis that includes the potential impact of future share repurchases and anticipated 2026 dividends. With that, I'll turn the call over to David.

Thanks, Ralph. Good morning, everyone, and thank you for joining us today. This call is somewhat bittersweet for me as it is my last quarterly earnings call after many years, Cigna Group. The CEO, I participated in close to 70 of these calls with you, and I'm pleased to be able to share strong results again on this call. Today, I'll focus my remarks on our strong first quarter performance and how we continue to deliver in a dynamic operating environment. And then I'll take a moment to address our leadership transition on July 1 and Brian Evanko will step into the CEO role to drive our company's next chapter of growth, and I'll transition to the role of Executive Chair. Following my remarks, Brian will provide a more detailed update on our business platforms and performance and then Ann will review additional details about our financial results and outlook, and then we'll move to your questions.

So let's get started. I'm pleased to report that The Cigna Group delivered strong performance in the first quarter, including total revenues of $68.5 billion and adjusted earnings per share of $7.79. All while we continue our disciplined track record of reinvesting back in our businesses to fund growth addressable market expansion and innovation. With our performance, we are raising our full year 2026 adjusted EPS outlook to at least $30.35 reflecting our disciplined approach and steady execution in an operating environment that continues to be shaped by many forces. Two of these froces are clearly rising to the top for customers and employers. First, affordability; and second, the need for health care that is more personalized and as a result, easier to navigate. We are addressing these expectations in an environment where health care demand continue to rise and the cost of new services like pharmaceuticals continue to grow to greater than inflation.

Against this backdrop, over the course of my tenure, there are 3 key attributes that our company has demonstrated time and again to fuel a successful track record of performance rooted in purpose and innovation. First and perhaps most importantly, we've been steadfast in our commitment to put the customer at the center to make the health care journey more affordable, personalized and overall easier to navigate. This commitment is what spurred us to improve our prior authorization process as outlined in our first customer transparency report, which was released last month.

Our goal is to make the process faster and more seamless while ensuring that care is to lift the right time and right place appropriately and safely to that end, we have removed hundreds of tests and procedures and services from prior authorization process in the United States, decreasing the volume of medical prior authorizations by about 15%. Our treatment to the customer also drove us to take an active role within the industry, which last week announced further progress towards stabilization of the prior authorization process. This is enabling greater automation and more seamless, efficient access to care while maintaining appropriate safeguards. This announcement reflects continued progress on the voluntary commitments our industry made in June of 2025, in coordination with HHS and CMS.

Second, our company has taken a strategic and disciplined approach to the way we shape our business portfolio, which Brian will address more in a moment. Through our approach, we remain sharply focused on where we can deliver differentiated value, and we feed those businesses with additional capabilities or a -- and where we cannot, we make the decision to exit. This process has honed our focus on the addressable markets where we have a right to win for the benefit of our customers, patients and clients, which has been a critical driver in our success for many years.

Finally, we have a proven ability to innovate and perform even in the most challenging environments, whether that is in periods of accelerated medical costs or during the COVID-19 just to name 2. In moments like these, when customers' needs and behaviors change quickly, we remain relentlessly focused on market centricity, customer centricity and micro segmentation. The introduction of our transformative rebate-free pharmacy service model is the most recent example. This multiyear investment in innovation will deliver the lowest price to the consumers for their brand drugs which will be 30% lower with full transparency each and every time. And this model for deepens partnerships with independent pharmacists, including those critical ones in rural communities. We call this offering signature, a name that reflects a new era in pharmacy services.

Now before concluding my remarks, I also want to speak briefly to our upcoming leadership transition. After my nearly 17 years as CEO of The Cigna Group, we are on track for our carefully planned transition on July 1, when Brian will succeed me as CEO and take on the role, and I will take on the role of Executive Chair. Brian has a strong history of prioritizing customer and client needs and decision-making grounded in our clear mission and enduring such a purpose. Looking ahead, he is committed to further the use of data and AI to drive affordability and personalization, which in turn drives value and sustained growth. With a strong foundation and clear focus I'm excited for Brian to take the helm to guide The Cigna Group to its next chapters of growth. And I look forward to working closely with Brian in my role as Executive Chair.

Now let me wrap up and summarize the quarter and our results. We delivered strong performance, giving us the confidence to raise our full year guidance for 2026. We delivered total revenues of $68.5 billion and earnings per share of $7.79. Looking ahead, our increased adjusted EPS outlook of at least $30.35 reinforces to sustained growth, durability and strength of our company. We are delivering in a highly dynamic environment, and we continue to invest with purpose through a customer-first orientation, driving disciplined portfolio shaping and innovating to personalize and modernize health care for the benefit of our customers and clients. We have a clear strategy and the right leadership team in place to capitalize on those opportunities ahead. And with that, I'll turn the call over to Brian to discuss our results in more detail.

Thanks, David. Good morning, everyone. First, I want to take a moment to thank David and acknowledge his strong leadership, both within our company and throughout the industry. Through his 35 years of service with the company, he has left an enduring legacy defined by an unwavering focus on meeting customer needs, a relentless partnership orientation toward others and a deep commitment to the communities that we serve. It's been a privilege to work with him for so many years. Looking to the future, there's no question that the status quo in health care is unsustainable. Costs continue to rise as does demand for health care services, an untenable equation. .

In this environment, the experience that I have gained over my nearly 3 decades with the company have sharpened my understanding of the needs of those we serve and strengthen my commitment to continue to deliver on our mission. I'm humbled and honored to take on the role of CEO in July with a focus on The Cigna group becoming the clear leader in consumer-focused and AI-enabled health services with an emphasis on clinically complex patients making care more affordable and more personalized for those we serve. In my remarks today, I will cover several topics.

First, I will share a few ways we are shaping our portfolio for the future, aligned to our strategy. Then I will review our first quarter business performance across our growth platforms. And I will go a bit deeper on ways that we are harnessing data, advanced analytics and AI to deliver more affordable and more personalized health care services. Turning to our portfolio. We have a disciplined and consistent approach to ensure that our businesses are aligned to and support our strategic direction and can deliver differentiated value in the market. Over the years, this approach has guided our decisions to either add to or subtract from our portfolio, which in turn has positioned our core health care businesses for sustainable growth. For example, last year, we added key capabilities in the highly attractive specialty pharmacy market. Our acquisition of CarePathRx provides us with further depth in infusion-related services.

And our investment in Shields Health Solutions provides us the opportunity to partner more closely with hospitals and health systems who serve patients with complex care needs and rely on specialty medications. On the other end of the spectrum are the businesses we have divested where the assets no longer support our strategic direction or have reduced management focus from our core growth platforms. Our divestiture of our Group Life and Disability business, which also meaningfully reduced the company's exposure to economic downturns is a prime example as is the more recent sale of our Medicare businesses. Divesting each of these assets enabled greater focus and investment in the remaining businesses within our portfolio, supporting our forward-looking growth path.

In keeping with this portfolio shaping discipline, today, we are announcing 2 additional actions. First, we are planning to exit our individual exchange business at the end of this year. We did not make this decision lightly and appreciate the importance of ensuring patients have continuity through the transition. There are no changes to coverage or networks related to this announcement. And we will support members through their open enrollment transitions into 2027. Second, as our industry continues to make strong progress on standardizing and automating prior authorization services, we have decided to initiate a strategic review of alternatives for EviCore. EviCore is a part of enabling how care is evaluated and delivered across the industry including working with numerous health plans to perform reviews and prior authorizations on their behalf. As David mentioned, prior authorization plays an important role in health care and we will explore options to continue delivering the highest level of service for health plans and the industry at large, while maximizing long-term value.

We see the potential for different approaches to standardize prior authorization across the industry improving transparency for customers and clients, reducing the administrative burden for providers and creating efficiencies for the industry. Both of these actions reflect a deliberate strategy to sharpen our focus on our core platforms where we have the capabilities, positioning and expertise to deliver differentiated value for the benefit of those we serve.

Turning to our performance in the first quarter. We started the year with strong results across both Evernorth Health Services and Cigna Healthcare. Overall, Evernorth earnings were slightly ahead of expectations. This was driven by the strength of our Specialty and Care Services businesses, which delivered adjusted earnings growth of 20% in the quarter, reflecting continued attractive volume growth. As the specialty pharmacy marketplace continues to grow we are well positioned across our suite of solutions, our strong supply chain and our expertise in inventory management and complex drug distribution.

Our ability to deliver a strong clinical support model continues to have a positive impact for patients and clients alike. We see this through higher adoption and adherence rates once patients begin taking biosimilars and specialty generics leading to better overall outcomes. Turning to Evernorth's Pharmacy Benefit Services business. Our results were in line with expectations. Our first quarter results reflect previously discussed impacts of large client renewals and investments as we progress toward our transformative new rebate free model. Named Signature. This week, we met with hundreds of leaders from our largest pharmacy benefit services clients. And there are a few consistent themes we're hearing from clients and prospects alike about the direction of our business.

First, our forward-thinking innovation is resonating for its focus on the consumer offering the lowest out-of-pocket costs at the pharmacy counter and helping clients navigate through a very complex and fluid external environment. As clients continue to face budget uncertainty driven by new drug launches and midyear market disruptions, -- our new simplified model will give clients clear visibility into economic value and greater predictability. Second, they appreciate that we are proactively leading through regulatory and legislative changes. We continue to hear from clients and prospects that they are seeking clarity, predictability and value for consumers. Our signature model directly addresses these priorities and supports plan sponsors as they address their obligations today and in the future.

Finally, our clients value our partnership in meeting their needs today while anticipating future needs. This feedback is reflected in a strong start to our 2027 pharmacy benefit services selling season. Finally, turning to Cigna Health Care. Our earnings exceeded expectations in the quarter and grew 18% year-over-year, powered by solid persistency, continued disciplined execution and MCR favorability. Our strong earnings performance is further enabled by our innovative offerings and focus on consumer experience improvements. Recently, Cigna Healthcare was ranked #1 by J.D. Power and digital experience satisfaction among commercial health plan members for the second consecutive year. We are also seeing Clearity, our new co-pay only medical plan launched late last year, generates strong market interest.

In addition to its simplified product design, Clearity features externally derived clinical quality measures and a single digital front door that gives customers integrated access to care and their historical claims data through our myCigna app. Taken all together, we're pleased with our strong first quarter performance across both Evernorth and Cigna Health care. The positive first quarter results and market momentum are further powered by our embrace of data and modern technology. By leveraging the combined power of data, advanced analytics and AI, we're able to drive greater customer and client satisfaction through improved affordability of care and greater personalization of services.

Let me offer a few examples. Starting in our Specialty Care Services businesses. Today, we are using a genic AI together with our clinical expertise to improve customer and patient experiences. This is enabling us to transform how prescriptions are processed, efficiently schedule prescription orders and proactively identify patients who need additional service. We do not use AI for clinical decision-making, but rather AI capabilities increase the speed and strength in the decision quality of our highly experienced clinical teams. In Pharmacy Benefit services, we are utilizing AI to enable better care and service to our customers. This includes leveraging AI in our signature model to improve member communication and notifications and help patients make decisions on their care journey and enhancing our capabilities to deliver the lowest out-of-pocket cost for consumers, including the GLP-1s, where we continue to evolve as new oral solutions enter the market and prices decrease.

And in Cigna Healthcare, we are using AI-enabled capabilities to improve outcomes through risk prediction models, identifying complex patients earlier in connecting them with our clinical teams. Our predictive high-cost claimants model identifies members with increasing care needs earlier in their clinical journey. This then enables targeted clinical engagements that improve affordability, reduce acute utilization and drive measurable cost savings. To date, for those customers engaged in this model, we see an average of $2,000 per member per year in savings, resulting in the elimination of unnecessary provider and ER visits. This improved high-cost claimant prediction capability has benefits across Cigna Health Care, for example, in the stop loss business.

More broadly, we are proactively helping our customers in highly personalized ways. The combination of our AI tools and contact centers and improved customer digital experiences led to a 20% drop in total inbound calls for digitally eligible customer in our Cigna Healthcare U.S. Employer business. And a 25% reduction for pharmacy benefit services members when compared to just 2 years ago. Ultimately, these capabilities allow us to go beyond administrative enhancements and deliver better health outcomes. As I wrap up, I'd like to reiterate a few points. Some of the notable headlines from our strong first quarter include continued momentum in our specialty businesses, underscoring powerful secular growth our differentiated capabilities and our expanded suite of solutions. Good progress on constructing our new signature pharmacy benefits model and positive market reaction to our innovation and evolution. And Cigna Healthcare results exceeding expectations with performance supported by our innovative offerings and focus on the customer experience.

As a result of this combined strength, we are pleased to increase our earnings guidance for the year to at least $30.35 per share. This is made possible by the great work of our teams and also through our continued deliberate focus on disciplined portfolio shaping which ensures that the appropriate resources and support are pointed toward the growth of our core businesses. This morning, we announced the thoughtful sunsetting of our individual exchange business at the end of this year. as well as evaluating strategic options for Evercore. Our results are also enabled by continued investments into harnessing the power of data, advanced analytics and AI driving new value creation and improved personalization and affordability for our customers.

As we look to the future, I'm excited about the progress we've made to date and how we're leading the way building with NEXT in health care. With the most experienced leadership team in the industry and continued partnership with David as Executive Chair, I am confident we are well positioned for continued growth and success. We look forward to hosting an Investor Day in September. We will share more and discuss advancements in each of our core businesses. Now I'll turn it over to Ann to cover our financial performance.

Thank you, Brian, and good morning, everyone. As Brian mentioned, we started the year with a strong first quarter performance. Key consolidated financial highlights for the first quarter include revenues of $68.5 billion and adjusted earnings per share of $7.79, representing 16% year-over-year EPS growth. With the first quarter results, we are raising our full year 2026 adjusted earnings per share outlook to at least $30.35. This outlook reflects the positive momentum in our businesses while maintaining a prudent view of the current moment. Now turning to our segment results. I will first comment on Evermore. First quarter 2026 revenues grew 9% to $58.4 billion, while pretax adjusted earnings grew 2% to $1.5 billion slightly ahead of expectations. Special team care services showed strong growth with pretax adjusted earnings up 20% to $1.1 billion. This performance reflects continued momentum in our fastest-growing business, including strong demand for specialty and increased biosimilar and specialty generic adoption which are key levers for delivering affordability, value to patients and clients.

Additionally, the income from our investment in Shields Health Solutions contributed to the growth in the quarter Pharmacy Benefit Services pretax adjusted earnings decreased 28% to $394 million, in line with expectations. The year-over-year decline of approximately $150 million in the quarter reflects the previously discussed renewal and extension of large client contracts as well as investments associated with the transition to Signature, our new rebate free pharmacy benefits model. As those assessments ramp through the year, the trajectory remains consistent with our prior commentary and expectations for the business.

Taken together, Evernorth's first quarter results reflect the deliberate evolution towards signature and greater focus on higher value care services and specialty capabilities. Turning to Cigna Healthcare. First quarter 2026 revenues were $11.5 billion, and pretax adjusted earnings were $1.5 billion. The medical care ratio for the first quarter was 79.8%. Cigma Healthcare results were favorable to expectations in the first quarter, driven in part by lower flu volumes and weather-related care deferrals. This year, we also have seen a higher proportion of individual exchange members enrolled in plan, which results in a lower first quarter MCR, which does not change our outlook for the full year.

As Brian mentioned earlier, as part of the strategic shaping of our portfolio, we have made the decision to exit the individual exchange beginning in 2027. This will allow us to focus on areas where we can best offer differentiated value to make a more meaningful difference in the health and experiences of those reserves. Our financial expectations for our ACA exchange business in 2026 remain unchanged. Overall, we are pleased with Cigna Healthcare's strong first quarter results.

Now turning to our outlook for full year 2026. Our first quarter performance was strong and we are raising our full year 2026 consolidated adjusted earnings per share outlook to at least $30.35 maintaining a disciplined and prudent approach to the full year. Regarding the cadence of earnings, we expect second quarter adjusted earnings per share to be approximately 25% of the full year outlook. In Evernorth, we continue to expect full year 2026 adjusted income from operations of at least $6.9 billion, and we expect second quarter pretax adjusted earnings seasonality and to be similar to historical patterns. For Cigna Healthcare, we now expect full tax -- full year pretax adjusted earnings of at least $4.525 billion and we expect pretax adjusted earnings in the first half of the year to be slightly above 60% of the full year outlook. We expect the second quarter medical care ratio to be slightly above the high end of the full year range with the sequential increase reflecting typical seasonality and business mix compared to prior years. Our full year medical care ratio guidance remains unchanged.

Turning to our 2026 capital management position. First quarter operating cash flow was $1.1 billion. We continue to expect the majority of 2026 operating cash flow be realized in the second half of the year, consistent with our prior commentary and last year's pattern. Our debt-to-capitalization ratio was 42.3% as of March 31 and 70 basis point improvement compared to year-end 2025. We expect this ratio to be lower by year-end 2026 as we balance debt repayment with other uses of capital, including share repurchase. .

Now to recap. Our first quarter results reflect strong contributions from both Evernorth and Cigna Healthcare, disciplined execution and the resilience of our diverse portfolio of businesses giving us the confidence to raise our full year 2026 adjusted earnings per share outlook to at least $30.35. And with that, we'll turn it over to the operator for the Q&A portion of the call.

[Operator Instructions] And our first question comes from A.J. Rice with UBS.

David, best wishes to you as you move forward. And Brian, congratulations to you on the new role. I wondered maybe just to drill down a little bit more into what you're seeing as you roll out to the to your clients, the new PBM model. I know it doesn't go live for external clients until 2028, but you're in the -- well into the '27 selling season. And I'm trying to think through, if I'm making the transition to the new model as a client, do I need to give you more than the typical notice? Does it take longer lead time for me to make that transition when do you think you'll get indications from clients as to the uptake there? And maybe just expand a little more on the comments around strong selling season, how much is being driven by this discussion versus just the general market environment?

It's Brian. I'll try to take each of those components of your question. I appreciate the kind words and both David and I appreciate hearing that from you. So thanks. Obviously working with you for many years. As it relates to Signature, our new rebate free pharmacy benefits model, maybe I'll just step back and give you a little bit of context for how we got here and how to think about the next couple of selling cycles to your point. If you think about the challenges we have here with health care in America, the affordability of prescription drugs continues to be 1 of the top challenges facing both patients and therefore, the entire pharmacy benefits industry and this is particularly acute for high-cost branded prescriptions, which today represent just 10% of all the prescriptions in America, but nearly 90% of the total drug spending and all key stakeholders, whether that's employers, whether that's brokers, whether that's drug manufacturers themselves acknowledge that the status quo is unsustainable.

So the market feedback thus far as it relates to our new rebate free signature model has been positive as clients and brokers invest the time to learn more of the details of our new model. As I noted earlier, we had hundreds of our largest clients together just this week and received a variety of helpful input from them. Importantly, this model though was designed with the patient at the center and our price assure capability guarantees patients the lowest possible out-of-pocket costs when they fill their prescriptions, whether that's through our negotiated price, whether that's the patient's co-pay or a cash paid alternative. And if the patient does utilize a direct-to-consumer cash pay alternative will ensure that out-of-pocket applies to their deductible. So after we got through some of these details, clients and brokers are excited about this model and treated to learn more about it.

And our legacy rebate free model, it serves a time to place. We're seeing increasing instances of unintended consequences where patient affordability is suffering. Additionally, we're seeing employers and other clients reviewing their obligations to employees and their family members and see the signature model as a simpler way of ensuring that those needs are met. So our capabilities are multidimensional and bespoke in the sense that they can meet a variety of unique clients. So as it relates to the selling season and how to think about this, the signature model will become our standard model in 2028. And as we have shared before, we expect at least 50% of our Evernorth Pharmacy Benefit Services members to be in the Signature model by the year-end 2028. The PDS selling seasons tend to be long, as you know. So by the end of this year, we'll have a much better picture as to the level of market interest to adopt COM-128. Right now, we are largely in the 2027 selling season, which is largely our existing models with continued evolution.

Some of the things we're seeing so far in 2027, though, we're on track for mid-90s or better retention again, which is consistent with historical norms. We ended 2026 with over 97% retention. Additionally, we've already secured some key new business wins for 2027 in Pharmacy Benefit Services, underscoring that our current solutions are resonating in the market. So we're meeting the needs today, and we're preparing to meet the future needs with our new Signature model, which steps over many of the affordability challenges that are in place today. So hopefully, that helps a little bit with reconciling all the different moving pieces. As it relates to 2027, our Cigna Healthcare book of business, our fully insured customers will fully adopt the new model. That's just the standard part of the renewal cycle with those individuals. We're really excited about the future and the Signature model points the way for the industry. Thanks for the question.

Our next question comes from Kevin Fischbeck with Bank of America.

Maybe just asking on the 2 new data points about reshaping the portfolio. Any way to think about the impact from the exchange side as far as capital you might recapture next year. And then the Evercore transaction, is that something that you were approached by the that you decided to do strategically? And should we be thinking about this as a transaction that would be slightly accretive? Or is this kind of a neutral transaction economically?

Kevin, it's Brian. So both of the portfolio shaping actions that we announced this morning, the sunsetting of our individual exchange business as well as exploring strategic alternatives for Evercore were decisions we took proactively. So you should not think of those as a response to any sort of other market activities as we're a proactive, deliberate portfolio shaping decisions that we took after stepping back, continuing our long tradition of disciplined decision-making with the long-term orientation.

As it relates to the individual exchanges, really, there were 2 primary drivers of our decision to step away from that business. One, we did not see a clear path to scale this business to achieve meaningful impact within the context of The Cigna Group's aggregate size. And the second factor is management focus for the organization. This is a small business for us today, and it's been shrinking in recent years. So the decision will allow us to further intensify focus on our core growth platforms across The Cigna Group, notably our rapidly growing specialty and care services businesses, our industry-leading pharmacy benefit services business and our flagship U.S. employer business within Cigna Healthcare.

To your point on capital, we'll free up some amount of capital, but I wouldn't view that as a particularly material again in the context of The Cigna Group. As it relates to core our announcement to explore strategic alternatives, again, as a result of a disciplined assessment process. And you can think of this 1 really being driven by 2 primary factors as well. Similar to my comments on the individual exchanges, the potential size of this asset within the context of The Cigna Group's portfolio made for a challenge relative to the ability to scale it and consume management attention and time. And secondly, as David discussed in his comments earlier, the continued progress around standardization and automation of prior authorization processes, let us to step back and assess the future of the business within our portfolio. Over the past 18 months, we're proud to have voluntarily announced a series of commitments to improve the methodology and tools around prior authorizations, all of which ultimately are designed to simplify customer and provider experiences.

And some of those commitments were specific to us at The Cigna Group. Others were in partnership with HHS and other industry participants. For example, just last week, we had a joint announcement related to the standardization of information that's required for many of the most commonly requested procedures. So all these prior authorization enhancements through standardization and technological progress opened new doors for eviCore business, which could potentially result in a partnership or a combination with other complementary industry participants. But there is no transaction to discuss. This was a proactive step we took to shape the portfolio. Hopefully, that helps. We look forward to providing more details on all of this in the coming months.

Our next question comes from Lisa Gill with JPMorgan.

I just really had 2 things I wanted to better understand. One was just the cadence of the cost, you talked about $150 million in this quarter for renewal plus the transition to the new model. How do I think about that for the rest of the year? And then secondly, very strong results when I think about specialty. Can you talk about some of the key drivers from a specialty perspective. Is this growth in existing clients? Is profit being driven by some of the comments you made earlier around biosimilars. Just if you can give us any color on how to think about your specialty business?

It's Brian. Maybe I'll start with just a few framing comments and then Ann can pick up on some of the drivers from a financial perspective. But overall, we're really pleased that our Evernorth business in total was slightly ahead of expectations powered by the strength in the Specialty and Care Services portfolio. As you think about the Specialty business, this is a space with really strong secular tailwinds, as we've discussed before, and we see the space growing, call it, mid- to high single digits on a pure secular basis. And then we have strong differentiated company-specific capabilities to deploy against that. And so in the quarter, we saw strong volumes, we also saw strong biosimilar adoption, and we had contribution from the Shield investment that we made late last year. And can unpack that a little bit further. .

In the pharmacy benefit services business, we were pleased with the performance of that as well, being in line with expectations and a solid start to the year. And you'll recall, we had 2 discrete headwinds stepping into the year 1 being our proactive large client renewals and the second being the investments to build out our new rebate-free Signature model. And as I was discussing earlier with A.J., as we continue to deliver on the present, we're simultaneously preparing for tomorrow through the build-out socialization of our new signature model with all key industry stakeholders, and that will be ready to scale in 2028. Ann maybe you can pick up a bit on the 2 components of Evernorth. .

Sure. So I'll start with Specialty Care first. And as Brian said, we're pleased with the results. We expected a strong first quarter in Specialty & Care, and we came in slightly ahead of expectations. We remain excited about the space, as Brian talked about, a strong performance in the quarter. So solid specialty volume growth. I'm going to point to 3 things. That's one. The second is a continued mix towards more cost-efficient therapies, so biosimilars and specialty generics. Those are delivering meaningful savings to patients and clients while also lowering reported revenue and supporting higher margins for Evernorth. And then the third, Brian touched on this, the contribution from Shield. So those are the 3 big drivers for the quarter. Taken as a whole, we're confident in delivering Specialty and Care in the high end of the growth range for this year.

The Specialty Care for PBF, new line double down results were in line with our expectations and consistent with the prior commentary that we've given around proactive renewals and extension of the 3 large clients as well as our planned investments to support our transition to Signature our new free bake remodel. So in the first quarter, -- if you just look at the dollars, PBS earnings were down about $150 million compared to last year first quarter. As you think about the run rate of that and then a ramp-up of some of the spending around Signature is weighted towards the back half. The numbers are in line with our prior commentary and our guide -- our overall guide for Evernorth. So -- with that, again, PBS was in line with expectations, and we remain focused and excited about our transition to Signature and confident in our shaping of Evernorth for the full year.

Our next question comes from Scott Fidel with Goldman Sachs. .

David, it's been quite a 1 over the last 70 earnings quarters out with you. So I appreciate all that dialogue over the years. And Brian, congratulate it to you, I guess, Brian, just in sort of the context of some of the strategic sort of updates that you've been talking about and some of the as you start transitioning into the C-suite. And just on if you can maybe also frame it around the 5 growth pillars that have been sort of at the core of the growth strategy for a number of years, but there's also been some evolution across some of those markets as well. Curious around how you see the continuity around those 5 growth pillars or do you see potentially making -- putting your personal touch on those, that approach to some degree as well.

Scott, I appreciate the question and the kind words. I'm sure David does as well. Maybe I'll just give you a little bit of framing for how I'm thinking about the future of The Cigna Group when I step into the CEO role in July. And I'll share a little bit of the problem statements that face our industry a little bit of where we're focused and hopefully, that merges with your point on where we're going to be focused from a growth standpoint. So First off, I'd just start by reiterating my gratitude to David and our entire Board for such a thoughtful plan transition as I step into this role, I'm simultaneously humbled and excited if you will, to be stepping into such a big job here and also feel a strong sense of accountability to our customers, clients, business partners, shareholders as well as my coworkers and their family. So we're fortunate to be right now performing so well across The Cigna Group as we outlined in our release this morning.

So I'm able to build on that historical success, carry forward the momentum we have and really attack the biggest problems in health care going forward. And the problems that we see really are threefold. The first 1 is affordability. Second 1 is, at times, there are fragmented customer and patient experiences. And the third 1 is we have a reactive Cigna care system. So our strategy at The Cigna Group is focused on addressing each of these opportunities. Now we have 3 strong high-performing growth platforms that we continue to invest in -- and to the point I'm making earlier around portfolio shaping, these 3 will continue to be fed with financial and human capital going forward.

One is our Specialty Care Services platform, which now represents about 35% of the company's income and is growing to 12% per year, as -- and just referenced earlier. Secondly, our pharmacy benefit services platform, also within Evernorth, about 25% of the company's income is going through the transformation that I was alluding to earlier, and we're confident on the long-term durability of that. And then finally, our Cigna Healthcare business, which represents the other 40% of the company's income, which is our high-performing health plan business, underpinned by our flagship U.S. employer business, which has shown a long track record of growing at above market rates. So those are the growth platforms we're going to be very focused on going forward in terms of scaling and delivering against our long-term commitments to our shareholders as well as to our customers.

Now when I take the CEO role in July, there are a few areas of greater intensification that I'd just like to highlight for shareholders. One will be the way we harness data, advanced analytics and AI to drive more personalized affordable customer experiences to a relentless drive to more affordable types of care to think generic drugs, biosimilars, more cost-effective locations for medical procedures. And third, shifting further upstream into care journeys through preventive care, diagnostics and encouraging behaviors that promote health and wellness.

And finally, through an investor lens, there are 3 commitments I'll make to all of you. one, strong organic execution of our strategy; two, disciplined capital deployment and continued portfolio shaping, always with a long-term lens. And finally, I believe that our equity has significant appreciation potential from current levels. Through continued strong execution, thoughtful strategic decisions and providing the right visibility to investors reach meaningful shareholder value creation opportunity. So hopefully, that feels familiar to you. We'll be continuing the momentum we have now and intensifying in a few of those areas you just made reference -- thanks for the question, Scott.

Our next question comes from Charles Rhyee with TD Callen.

And first, let me echo congrats to the bulk of you going forward here. Maybe if I could follow up on Lisa's question and drill down a little bit more on biosimilars and the strength we saw in specialty. Perhaps how much of the results we saw in the quarter were driven by formulary genes really to try to drive biosimilar adoption, which I think could be also positive for Accredo. And I'm thinking in particular around biosimilar STELARA, which I think you're also manufacturing through. Maybe talk a little bit about how the synergies between the different parts of the Evernorth business is helping in this regard and perhaps how much of that was -- is driving this kind of growth? And is that something we should expect, particularly as we see more biosimilars coming to market over the next few years? .

Sure, I'll start on this one. So I appreciate you highlighting the strength of our specialty platform as made reference to earlier, really pleased with the strong momentum there. And we believe biosimilars and specialty generics are critically important to driving affordability for the health care system at large in the future. And if you think about the journey we've been on here, we introduced a HUMIRA 0 out-of-pocket a couple of years ago. And the penetration of those biosimilars have continued to grow. And so it took a further step forward into the first quarter of '26. Similarly, our STELARA 0 patient out-of-pocket was available first in May of last year. So if you're doing the year-over-year, it was not in the first quarter of '25, it is in the first quarter '26.

We've seen nice growth in the penetration of that over the course of the 10 months or so since we introduced it -- and this year, we're excited about generic Revlimid, which is especially generic that will have supply constraints ease and that will add to contributions as the year unfolds. And finally, I would just remind you, we made our investment into Shields in the third quarter of last year. So as you think about the way that the timing will unfold on the financial contribution there. as you model the balance of the year. But those are all areas we're really excited about. In addition to core volumes that continue to grow -- we saw a particular strength in the quarter in a few areas like severe asthma hepatology fertility that saw outsized percentage growth rates in volumes in specialty. So we're really excited about that platform in the future. I think David wants to way in with a few thoughts here as well. .

Thanks, Brian. And Charles, thanks for the question. I just want to amplify 2 pieces that Brian articulated and then drill down for 1 more moment. One, our model still embraces choice, so affording choice with the diversity of who we serve and type on what you heard is the incentive alignment. So whether it was HUMIRA or STELARA. STELARA designing it with the $0 out-of-pocket for the consumer, for the patient, very strong value delivered to stakeholders, the employer financier as well as the consumer.

Click down on and complement the team on, the team was able to harness effective use of AI to identify the conversion strategies in a highly personalized way, which had high NPS, low friction and high continuity for both the patient and the physician. The result of that is the conversion. The result of that is more value delivered, but higher satisfaction and then staying power of the conversion to the biosimilar. So it's an example where Brian talked before about harnessing data those few together in AI a highly personalized basis to deliver the outcome on the biosimilar, but to do it in a very customer patient-friendly way and a physician coordinated way. Thanks for your question. .

Our next question comes from George Hill with Deutsche Bank. .

Brian and David, again, congratulations to both you guys. I was just hoping you might update us on your 340B exposure given where you guys are with CarePass now and Shield. And kind of how should we think about how the -- and I don't know if you're doing to quantify what both of those units are contributing to the business right now from an operating earnings perspective. And just kind of how to think about the exposure to that segment, given what's going in the drug space?

George, it's Brian. I appreciate the comments and the question. So as it relates to 340B, you can think of that as a component of the Specialty Care Services platform within Evernorth that we just made reference to. And actually, if you go way back at the time we acquired Express Scripts, looking at the Accredo asset that realized it did not have very much 340B activity within it relative to others in this space. So over time, we built a suite of capabilities that allow us to partner with hospitals and health systems more effectively to help them manage their 340B related activity.

So we had a small acquisition several years ago, Verity, more recently, or acquisition of CarePath and the investment we made in Shields all allow us to serve hospitals and health systems in a way that allows them to optimize their relative performance around 340B. So you should think of it as indirectly supporting, again, hospital and health systems through our service-based offerings as opposed to being a scaled 340B contract pharmacy as it relates to the portfolio. So overall, it's a component of the Specialty and Care Services portfolio, but the lion's share of that business continues to be our core Accredo specialty pharmacy as well as our CuraScript distribution capability. So per to think about it in that way as opposed to being its own P&L, if you will, within the broader Evernorth portfolio.

Our next question comes from Justin Lake with Wolfe Research. .

I wanted to focus on a and specifically on the reported noncontrolling interest in the quarter of $226 million. NCI increased dramatically over the last years and this quarter more than doubled versus Q1 '25. So just given how significant this item to come, I wanted to dig in here for a minute. My impression is that NCI is driven by your GPO, which is, I believe, both the joint ventures, I wanted to confirm a few things. First, what are the main JVs driving this NCI. On average, what percentage of these JVs are owned by the company versus your partners? And what specifically is driving the 100% plus increase in the quarter, for instance, if the partners get significantly larger piece of the JV? Or is this completely driven by a doubling of earnings from the JVs? Thanks for the details. .

All right, Justin. So I'll start. So just to frame it a bit. We support Health in a variety of variety of ways, including procurement, value-based services, and we work across a broad set of relationships with health plans and related entities. Through these partnerships, clients benefit from our ability to drive value and we're able to deliver flexible competitive solutions. So the NCI line item includes minority earnings from a number of joint ventures and partnerships, which you mentioned. There are multiple different structures and ownership levels. So the growth in NCI doesn't directly correlate to the same levels of growth in our earnings.

If you're looking at the year-over-year increase in the NCI line, that was primarily driven by a new joint venture, 1 of our largest clients and the additional economics are passed back as part of the previously discussed renewals that we did. So JVs can have various structures for this one, the new 1 that drove the increase despite us holding a majority share, most of the economics are passed back and have no impact on our earnings. This was known and fully contemplated in our guidance for the full year, and we are really pleased and happy to continue to be a partner of choice for the largest those sophisticated purchasers. I hope that helps.

Our next question comes from Erin Wright with Morgan Stanley. .

Great. With some of the optimization in the portfolio kind of announced today, I guess, should we really think about this, are we read this as you're really trying to push into specialty? Like how central is specialty to the strategy? How do we think about this in the context of your capital deployment priorities from here? And on the flip side of that, what is the commitment to other parts of the insurance business and remind us of the synergies across the integrated model, how that aligns with this sort of new AI-enabled consumer-driven health care services company?

I think there are a few different topics in there that I'll try to lead together as best I can. But as it relates to the portfolio shaping that we announced this morning as I was responding to a earlier think of the choices here as being proactive decisions based on a deliberate review of management focus, relative size and scale, as well as the degree of standardization and automation, for example, that's transpiring in Evercore, -- so you should think of this as the core drivers. As it relates to specialty, we're already a scaled player there, and we love this space. So there should be no doubt about that. but that's not at the -- it's not trading off growth in our other growth platforms at all.

So you should think of we want to continue scaling our specialty business for sure. We want to continue to scale Cigna Healthcare for sure, and we want to continue to transform the pharmacy benefit services model. So all 3 of those growth platforms will continue to get resources and investments as opposed to being a specialty alone. That said, we do continue to see further upside in our specialty business. If you look at our capital deployment in the last couple of years, it's gone in an outsized way into the specialty space with our acquisition of CarePath, and the investment we made into Shields. And going forward, we'll continue to have a balanced capital deployment framework once I become CEO, you should not expect to change as it relates to the way we think about deploying capital. We'll continue to prioritize internal reinvestment. We'll continue to pay an attractive shareholder dividend. We'll continue to make sure the capital structure is appropriate in terms of leverage ratios and we'll use share repurchase and strategic M&A on a targeted basis.

And our focus from an M&A standpoint, the current time continues to be targeted strategic bolt-ons like your broader umbrella, we're very excited about the specialty space. We'll continue to invest there. We'll look to scale it. But again, it won't be trading off against other parts of the company's growth platforms. And looking forward, we do continue to see attractive opportunities to weave together our multidimensional capabilities across The Cigna Group. So many of our Cigna health care clients value the fact that they have a combined medical, pharmacy, behavioral offering that brings together the best of the company into 1 singular offering for the benefit of patients and their families. So hopefully, that helps to hit on your different pieces in the question there.

Our next question comes from Jason Cassorla with Guggenheim.

Great. Congrats to David and Brian as well. Maybe for the health care MLR, the 79.8% in the quarter versus the slightly below 81%. And you had guided to. Was that delta completely explained the way by flu weather and the exchange seasonality? And then maybe just broadly, can you delve in a bit deeper on what you're seeing in terms of employee cost trend any utilization categories where you're seeing favorability. And you've focused and highlighted site of care. Just not sure if you're seeing or maybe you can update us on some of the mix shifts, maybe perhaps helping out cost trend -- or if you're seeing anything from an absolute service category from utilization trending better or worse? And then maybe lastly, can you just help us bridge a little bit on the second quarter MLR coming in slightly above the higher end of the full year guide would be helpful. .

Okay. Thanks for the question. So I guess just starting as I noted in my prepared remarks, the Cigna Healthcare results were ahead of expectations. And I would characterize that as driven by strong fundamental performance, including retention, rate execution and cost trends, across both U.S. employer and individuals. So if you look at the quarter, during the quarter, we observed lower flu respiratory volumes as well as weather-related care referrals, which benefited results. And then on the Individual business, we saw the higher percentage of plan members, which carry a lower MCR at the beginning of the year and a higher MCR at the end of the year.

In terms of any drivers, I would core categories, I wouldn't call out a single driver as outsized or category as above our expectations. The contribution was fairly balanced. Cost trend remains high, and we planned and price for it. So that's on that for itself. When you think about the sequential increase from first quarter to the second quarter, that reflects both normal seasonality and other seasonal and services that are unique to this year. So with regard to normal seasonality. As a reminder, the Medicare business, which we divested last March, had a flatter MCR seasonality than our other businesses. So this year, normal seasonality will be steeper going from 1Q to 2Q. For other seasonal and timing factors that are unique to this year, I'd point to 2 things. I mentioned the higher proportion of bronze numbers in the individual business that compared to prior years.

So that results in a steeper pattern throughout the year with the steepest jump happening in the second quarter. And then there are also timing factors, including weather-related and care referrals that impact the seasonality and will impact the quarter. But overall, we're pleased with the strong start to the year. The full year guidance range of [ 837 to 847 ] remains unchanged and at this point of the year reflects the prudence. .

Jason, just if I could add 2 quick things to a very comprehensive summary there. We're really pleased with the performance of the overall Cigna Healthcare business. And we said to be able to raise the guide for the year based on what we're seeing so far, which includes an appropriate degree of prudence for the balance of the year. As Ann said, we continue to plan for and price for sustained elevated cost trends. On the positive side, they have not accelerated. They remained elevated. So to the extent we do eventually see some deceleration that offers some upside to our outlook. But we're excited with the performance of this portfolio for sure. So thanks for your question. .

And our last question comes from David Windley with Jefferies. .

I wondered if you could highlight or discuss uptake in the GLP-1 programs that you have that you've highlighted in the past in [indiscernible] and Circle -- and then any other similar programs that you would highlight as particularly attractive or popular among your customers right now? .

David, it's Brian. So maybe I'll just talk about the GLP-1 space more broadly and then hit on some of the programs as we work our way through this. As we discussed on prior calls, GLP-1s are a very visible example of the broader wave of drug innovation that's transpiring in America and around the world, quite frankly. And as it relates to coverage for weight management in particular, we continue to see, on a client level, the percentage of clients covering weight measurement be relatively stable from 2025 into 2026.

Now those clients are increasingly looking for programs such as in circle and reach to provide the clinical and lifestyle support to make sure that the weight management programs are designed are working as they're designed to be, meaning -- we're not seeing micro dosing. We're not seeing people start and stop on the protocols, et cetera. So that's really the intention of those programs. And we continue to see -- we had 12 million plus enrollees in the Circle program numbers continue to grow each month across our overall employer book of business. But as I made reference to the coverage rates are about 50% in our Evernorth book of business, which tends to bias to our larger employers, they're about 20% in our Cigna Healthcare book of business, which tends to bias towards smaller employers.

But when you think about where we are with GLP1 more broadly right now, the ongoing tension here is affordability versus employee and family member satisfaction. So employers know this is a very popular benefit. They also know that it's a net cost right now to their overall health care programs. On the bright side, as oral versions are introduced and you see supply strength ease, this should help with future affordability by driving down the net cost of the GLP-1 drugs. But the tension between employee demand and employer affordability will continue to persist. And 1 of the things we've been very focused on, in addition to our great clinical programs is innovating around financing solutions. So we're seeing some employers and plan sponsors cover the full cost of GLP-1 drugs. Others will cover a portion but ask for co-pays to be paid by the employee or falling numbers.

Others are sponsoring coverage on more of a supplemental benefits chassis, where employee will pay the full amount. However, they'll benefit from our thousands of real-time clinical safety checks and then have the option of selecting additional lifestyle and clinical support programs for their members who utilize GLP-1s. So all these moving pieces are contemplated in our guidance. We continue to lean in to our both platform and take a leadership position in supporting employers and other plan sponsors around their GLP-1 strategies. Hope that helps, Dave.

Thank you. At this time, I'll turn the call back over to David Cordani for closing remarks. .

Thank you. I'll have up briefly here. First, thanks for your time and your questions. Second, we're clearly proud of the results we delivered in the first quarter and confident we will deliver on our increased guidance for 2026. I do want to reinforce after 17 years of leading the organization, how much I appreciate our colleagues around the world and the commitment they bring to work every day in serving our customers and patients in partnering with our clients in the relentless orientation around innovation and active voluntarism to make the communities better. .

On a final note, I've valued my interactions with each 1 of you throughout the investor community during my tenure as CEO, and I look forward to continuing to serve the Cigna Group as the Executive Chair. Thanks for your time, and have a great day.

Ladies and gentlemen, this concludes Cigna Group's First Quarter 2026 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) 405-7290 or (203) 369-0603. There is no pass code required for this replay. Thank you for participating. We will now disconnect.

Next session and -- for joining us here today. And I'm here with my colleague, Ryan Langston, and we're pleased to have Cigna as our next presentation and to present from the company we have Ann Dennison, Chief Financial Officer; and Adam Kautzner, President of Express Scripts and Evernorth Care Management.

So maybe to kick things off, Ann, I think you wanted to have a couple of comments.

Sure. I'll be very brief. I just want to say a few things. So we reported our fourth quarter full year '25 about a month ago. Really pleased with the results that we achieved in 2025. 2025 with expectations that we shared, and we were able to keep those expectations steady and deliver on them in 2025, which I think is a differentiator for now in this space. We're excited about the FTC settlement and what that means. We've been for over a year now, building a new rebate-free model, which Adam is going to talk a bit about. We're excited for that. We're excited for the fact that PBM reform, when you put all these pieces together, we're positioned very well in the context of the way that we're looking forward. We've been very deliberate in how we've shaped our portfolio of businesses.

And as we think about the long term, we have confidence in 2 things: one, delivering on at least $30.25 a share in 2026 and then delivering on our 10% to 14% EPS long-term growth algorithm over the long term.

Great. so I think maybe we're going to switch over a little bit and maybe let Ryan kind of start talk a little bit about Cigna Healthcare and then we'll move to...

Okay.

Sure. Stop loss, obviously, a huge topic in 2025. I think fourth quarter came in just a little bit above maybe where we thought, but still overall, it seems like the repricing on that product has been successful. It sounds like it'd be a little bit more successful going into '26. So maybe in terms of recapturing margin and getting that business back where you want it, maybe in '26, even into '27. Maybe talk about the steps you've taken and maybe further steps you could take as we move into next year?

Sure. So just as a reminder, at the end of 2024, we had some unforeseen trend in the quarter that we weren't able to price for in the 2025 cycle. And so our commitment was about 1% margin recapture over a 2-year period, most of which will happen in '26 and in '27. And it's all about for us striking the right balance between pricing and persistency and recapturing that margin over time. And so we were successful in the 2026 cycle. We've got some more to do in 2027, but we're on track to achieve our goals of recapturing that margin over the 2-year period.

Great. And then just from the fully insured standpoint, that part of the book performed decent pretty well in 2025. I guess maybe what are trends that you're assuming for the guidance in that range for that book? And maybe just any particular pockets of utilization we should be worried about, plus or minus?

Yes. I mean -- so we've talked about this a bit when you look at sort of trend in that book and more broadly, I'd point to the 3 largest contributors to trend that have held true for at least the last couple of years. One is behavioral health. Two is our specialty injectables, so specialty medicine. And then the third is inpatient surgeries. And that has held true. We plan for that. We continue to see those as the biggest growth in cost -- in both unit cost and in utilization across the book. And so we planned and price for that going into this year.

And we're working -- so our consumer, the patient is at the center of everything we do. So we are very focused on how do we bend that curve? What can we do in order to make those prices -- I mean part of it is a rebate-free model, but we're doing things on the -- across the ecosystem in order to try to bend that cost curve.

Got it. Charles?

Okay. Obviously, rebate-free model you mentioned earlier, obviously, been a big topic here. I guess the first question, since the introduction of that at the third quarter, maybe talk a little bit sort of the reception from plan sponsors in regards to that?

Sure, Charles. Happy to do that. We're thrilled with the introduction of our new rebate-free model that we launched back in October. Receptivity so far has been very strong from a client perspective. They're certainly interested to learn more as our benefit consultants. It's unlike anything else that has ever been entered into in the market in decades. So it is new, it's fresh, it's different.

And yes, we did start with the consumer and addressing the challenges that a consumer has today around access, affordability and ultimately improving overall patient outcomes. We've also been responsive to many of the components that you'll see within PBM reform. So we're delinking our fees. So it's going to be a simple administrative fee that will be charged for our services. We are addressing the unpredictability of rebates today. So if you look at Inflation Reduction Act, if you look at what's happening with most favored nation biosimilars, rebates themselves have become a bit unpredictable in the market. We've had to adjust rebate guarantees because of it.

So from a client perspective, that's resonating. It also addresses with this new model, the fiduciary component. And so there have certainly been concerns around fiduciary from an employer perspective. It addresses those types of challenges. But regardless of the positive feedback so far, we are still going to continue to offer a rebate model, too, because we want to make sure we're responsive to the market. We meet our clients where they are, and many of them might be on a different change curve than others. When you factor in PBM reform, though, we've been one step ahead of the market. We expect that most of the market will have to move in this type of direction to a flat fee administrative type of market for the long term.

And maybe just to help the audience, in a rebate-free model, right, the understand the way I understand it is that you are capturing sort of the discounts at the point of basically purchase between the pharmacy and the manufacturer, right? And so that when they are then billing to Cigna, then that's sort of what they're billing, right, their invoice cost. So you've negotiated that discount for your book of business with manufacturers. Can you talk about how then the formulary still works within this kind of structure?

Sure. Yes, happy to do that. So the new rebate-free model is, you could call it a supplemental discount. So we're going to negotiate that directly with drug manufacturers, no differently than we negotiate other discounts with them today. But this discount isn't going to be retrospective. It's not going to be based off a reconciliation or be opaque. It's going to be cleaned. It's going to be upfront. Members will be able to see it on the app when they go in to price those products and be able to then get that lowest net cost. So that component of it is really exciting as we look forward to the future and the overall member access and member affordability, and it's responsive from a legislative perspective.

From a formulary perspective, it essentially will function the same way as it does today. So we will still be focused on lowest net cost. This new model is going to still have a function for lowest net cost. So I would -- we expect formularies decision-making to be to function in a very similar way as how they function today. We'll still be leveraging competitive classes and the competition in those classes and aggressively negotiating for those discounts. They just manifest as an upfront discount that's going to be benefited by the consumer today versus a rebate that today may only be enjoyed by the employer.

Can I ask kind of a simple question? I understand like what we're doing here allows the member to benefit from their upfront cost. But isn't that really just a benefit design function? Like there's nothing stopping employers today to change their deductibles or their co-insurance and payments to allow them to effectively capture the same value. Isn't that true?

So employers could certainly adjust their benefits. So if we were in a flat co-pay world and know you paid $25 for every brand, right, this wouldn't be needed. But we all know the proliferation of deductibles, high co-insurances, and that's been the trend in the market. This is responsive to that trend. And by us negotiating these discounts upfront, on average, a drug that has a discount today, it's about 30% off. So these members for the 10% of branded drugs and for those that have discounts within that 10%, it's going to dramatically reduce their cost. And it goes right at most of the cost that's in the system today because although only 10% of prescriptions in America are brand drugs, they account for about 88% of the total cost, which is an astonishing figure.

Yes. I think one big question that we always get a lot is sort of what does the margin profile of the PBM look like into the future, particularly as you implement this new model. And one of the things you mentioned is we are delinking fees from the price of drugs and there's an administrative fee. And I can understand maybe at the start, that means you can kind of reprice -- you set that fee of what you were kind of making beforehand. But when we look at drug price inflation versus, let's say, CPI, obviously, that's probably going to be a difference. How do you preserve sort of the economics as we go forward would you say?

So first off, I would say with the Inflation Reduction Act and other changes that are happening in the market, drug price inflation, especially in competitive classes, you're going to continue to see likely higher prices when they come out, but less inflation going forward than what we've seen historically. Noncompetitive classes where effectively a drug has a monopoly, you may start -- you may continue to see that type of inflation.

In terms of our pricing, yes, we are delinking our fees. We are going to have simple administrative fees. Those may be per member per month or they may be a per prescription. So whatever a client wants to do, we'll be able to be responsive to those pieces. We will be able to -- since we know our margin profile today and for the different types of business and what does that mean from an administrative fee. And so that will be converted. So we expect that margin profile to be comparable. We do expect that we can continue to realize efficiencies every year like we hold ourselves accountable to be able to do. But there also may be certainly, yes, an increase in those fees going forward year-over-year.

On top of that, though, we're continuing to build out additional products and services, especially in our clinical services area where we're taking risk on improving patients' adherence, improving formulary compliance and their overall health. We have today medical data on over 40 million Americans, prescription data on over 100 million Americans. And so leveraging all of that data, we're continuing to create new products and solutions, which create additional upside as we sell in those additional products and services. But that fee, you can think of as being comparable where it is today and where it will be tomorrow within the new model.

Got it. One of the big pieces, right, is the amount of investments that you've kind of called out over the next couple of years. I think you've cited at roughly, call it, $300 million per year in this year and into next year. I guess 2 questions. The first is sort of I think that was kind of an estimate that you gave beforehand, maybe talk about sort of what you're deploying so far in terms of that $300 million target this year? Maybe what are you spending it on in the near term? And then second, should we expect these investments to continue past '27? Or does this actually become more of a tailwind as we think about '28?

Maybe I'll start, Adam, if you can add anything that you'd like to add. So as a reminder, coming out of the third quarter, we started to share this information. We didn't give a point estimate on the investments, but roughly in the range. And what it represents for 2027 -- 2026 and 2027 is basically the investments that we are doing to support the launch of the entire new model, and that's transformational, as you can imagine. So investing in technology, that needs to be retooled in order to handle this new model, investing in the people that need to work on the recontracting.

As Adam has talked about, we're recontracting with manufacturers. And so there's a lot that goes into that. So the investment -- and it has already started to some extent. We'll see more of it in the back half of this year than we will in the front part of the year. And again, we'll see roughly an equal amount in '27. And you asked about sort of does it just go away? In 2028, it starts to dissipate, and we would expect it to go away over time, but not all on one shot.

Okay. I want to maybe jump back something that Adam, you kind of mentioned before. If we think about the settlement with the FTC and the requirements there as well as the PBM reform measures passed in the appropriations bill, right? A lot of it is around increasing transparency requirements, more visibility for plan sponsors as well. Maybe talk about sort of what you need to do outside of the rebate-free model to comply with those and sort of -- obviously, the rebate-free model aligns very well with those, but maybe talk about sort of what changes in the traditional model that you need to undertake to be compliant.

Yes. So the -- we're thrilled to have the global settlement with the FTC behind us. We certainly welcome the appropriations bill and PBM reform and what that may mean for patients long term. Both of those pieces, we walk into eyes wide open, yes, with the new model being fully responsive. And you look at the key elements of those pieces, which are the rebate-free, but the additional transparency that we will continue to now be able to offer and expand delinking our fees, the pass-through moving all ERISA plans to pass through once the appropriation bill goes into effect. And so we're already moving in that direction, right? So many of the key elements of the delinking, the full pass-through, those are all components that we are addressing today.

Additionally, we are continuing to work to expand and make sure whether it's within the FTC compliance of we're going to be connecting to TrumpRx. We're also going to be connecting to many other direct-to-consumer and cash solutions across the market. We're expanding the functionality of what's called Price Assure.

So Price Assure will go out and look for the lowest price, whether it's cash, direct-to-consumer or within the benefit. It's going to pull that lowest price into the benefit. The benefit to the patient is we're going to do the 18,000 safety and quality benefit checks in that prescription. We're going to guarantee them the lowest price that exists out in the market. We're going to apply it to their deductible. So it's a big win from that perspective. We keep the script. The employer is able to keep that script in the ecosystem. And for the patient, they get the lowest price plus all the safety and quality.

So those are the types of changes we're making within the traditional benefit today and our ability to ensure that we can continue to offer a sustained benefit that is going to transition to pass-through as well long term post 2028 as regulations are finalized for the appropriations bill. But we welcome those pieces. We're well ahead of the market there. Us having new options and offerings and having spent the last year of thinking about this and putting into action a piece does keep us well ahead of where the market is, and that's resonating with clients and benefit consultants because we're continuing to be innovative and responsive to what needs to get done.

I asked at the beginning sort of the response from plan sponsors, but maybe talk a little about what the response from pharma manufacturers? How has that been?

Yes. So we are actively engaged on a daily basis of talking with drug manufacturers about the new model, the rebate-free component of the model. Again, we're still going to be negotiating rebates. We're still going to have market-leading rebates, and that will be available within the traditional model. We're targeting the largest manufacturers to start with. So we've tiered the manufacturers. We've had very productive conversations. We are going to have to recontract the whole market, same for pharmacies. But conversations are progressing well. They understand the benefit of this because they want what we want, which is lower prices for the consumer.

Today, they offset that with their co-pay discount cards and those types of things. There's less of a need for those things if I'm lowering patient out-of-pocket on average by 30% on these branded drugs. That means we can go and extract more of that discount from drug manufacturers what they're paying today, incorporate it into the base supplemental discount that we'll be negotiating for tomorrow. We also will be increasing the level of adherence for patients. There are about 10% of prescriptions that today go unfilled because of cost usually, and they're left at the pharmacy counter. We're going to reduce that number by putting these types of actions in place, which is going to expand affordability, access. Ultimately, that's good for drug manufacturers as well, and it's good for patients. So there's a win all the way around that's resonating really well so far with manufacturers.

You guys put out a target of 50% of your clients by -- for 2028. Does -- if I'm not mistaken, does that include the likes of Prime and Centene, and sort of your big TRICARE? Or is that exclusive of those 3?

So some of those plans are already on, yes, very transparent models. So as part of -- we expect that many of those will continue to transition into the transparent models that they're already on today as part of what that base is. But we do expect still for a large percentage of our commercial book of business, core employers and labor unions to also transition to the new model in 2028 and beyond. We do want to continue to be responsive, though and offer multiple different options to the market.

But again, where PBM reform is going and where additional transparency requirements are going, this new model fully aligns with all of those pieces. And when you incorporate in concerns around fiduciary and those types of things and the unpredictability of the current rebate model, we expect that there's going to be a lot of uptake of this new model.

Got it. I want to ask a little bit separate question. Senators, Warren and Hawley have reintroduced a bill in this Congress looking to separate not just you guys, right, but just in general, managed care from owning PBMs or pharmacies. It doesn't seem like there's a lot of appetite on Capitol Hill necessarily for this. But maybe talk through a little bit about what that means? How could you respond or how would you think to respond?

Our organization steadfastly continues to stand for ensuring that patients have affordable access to medications in a fully transparent environment. Unfortunately, what Senators Warren and Hawley are calling for is in complete conflict with that. It actually reduces a consumer's ability to -- for choice. It will increase the cost of medications and ultimately reduce overall transparency and could affect the health of those patients.

So unfortunately, for us, we aren't in agreement with those things. We actually challenge a similar type of bill that was in the state of Arkansas last year. And we didn't take that lightly, but we did file a lawsuit. The judge did grant us an injunction there. So limiting choice and increasing cost for patients is not something that we are in agreement with. I'm not going to expand any further on that one, but...

That's fair.

But, yes.

Maybe I want to shift gears and talk a little bit more about Specialty Pharmacy. Obviously, Specialty and Care services, you're kind of guiding to the higher end of your long-term adjusted pretax income growth target of 8% to 12% this year. Maybe help us understand sort of what is underpinning sort of your expectations for that to start.

Sure. So as you said, we're guiding to the top end of the range, and there's 2 components to that. One is the Shields investment. The other is the core, and I probably should have said those in the opposite way, is the core business and the growth that we're seeing there. And so when you think about the core business and what's driving the growth there, biosimilar adoption has been a tailwind for that part of the business. And we've seen -- and as we look forward to 2030, we've got about $100 billion of drugs that are expected to go the biosimilar route. So we continue to play a leading position in that space. The adoption of biosimilars is a net positive to the organization. There's a net detriment to PBM. There's a positive to the consumer, and then there's a positive to the Specialty and Care business, but a net positive to us overall.

And when you think about sort of the biosimilar pipeline, what would you expect? Like what percentage would you expect to go through something like Quallent or your own distributing of CuraScript or versus just bringing those products to market? Is it an expectation that more of it goes through your own channel? Or how do you think about that?

If you look at the performance of the Quallent, HUMIRA biosimilar, it's been very, very strong at Accredo. And I would expect for STELARA that we continue to see very strong offerings in that space too.

And any others that are coming in the near term that you think is a good fit for Quallent?

We're always looking at different opportunities that might fit the bill. But the largest ones are certainly ones that we've talked about thus far. Those are the largest in the [ inflam ] class, which have driven so much of the share so far. There's less of an opportunity in biosimilars as you look out into '27.

If you think about our 2026 guide that we've given, HUMIRA, we've got vast majority is already on the biosimilar and STELARA is a little less than 50%. So as we look out for this year built into our expectations is growth in both of them with more penetration.

From [indiscernible]. Got it. Maybe switch gears a little bit to Shields. You kind of mentioned -- and you mentioned a little bit earlier, it's kind of an interesting investment to get into sort of health system space. And I think part of it, it seems like health systems are really actively building out their Specialty Pharmacies. It's a revenue stream for them. It's a way to keep in touch with patients once they get discharged. Talk about sort of how that fits into your strategy going forward, particularly it would suggest a way to play the channel that's growing outside of what you're traditionally doing in Specialty Pharmacy? Or is there a way to kind of integrate both together?

Yes, Charles, I mean, you said it exactly right. So you think about the specialty space with over $400 billion of total addressable market. And then if you split that down into the direct-to-patient portion of it, that's 60% of it. That's the space that we play in already. The other 40% is the provider-to-patient space, which includes where Shields is and where we are not an industry leader in our current model. And so we're really excited about expansion into -- further into the other 40% of that addressable market. And we think there's a lot of synergy between what Shields does and where we can play.

So if you think about CuraScript and our ability to distribute for Shields, and they're serving over 1,000 hospitals, 80 hospital systems across all 50 states. There's a lot of opportunity there. There are ways for us to help them with inventory management and other things in that same ecosystem, but we think there's a lot of synergies that we'll find working together and expanding our addressable market through the process.

Got it. Maybe in the last couple of minutes, switching gears a little bit to capital deployment. Obviously, investments coming related to rebate-free model. You kind of talked about not to expect any kind of significant levels of share repurchase in '26. Maybe just remind us why that's not necessarily possible given sort of what the cash flow profile looks like? And then maybe how we should -- would you expect that to pick up in '27 as we move past this first year?

Yes, there's a couple of things to point out. So we are expecting cash flow from operations of at least $9 billion in this year. Why we've sort of given the guide on share repurchases and the way that we've done it is less about the investments that we're making. We're always prioritizing and making investments. It's more about the timing of our cash flows. If you look at last year, you'll see our cash flows were back half year weighted. And so we expect that again for 2026.

We also ended 2025 with a 43% debt-to-cap ratio, and we want to get that down closer to 40%. And so the combination of the back half weighting plus some debt repayments pushes our repurchases to the back half. And we get less of [ the bank ] for our buck in terms of share count because of the timing of them.

For 2027, I think it will -- we think repurchases are really attractive. We want to do that as much as possible, especially at the price that we're at right now. And so obviously, we're going to be focused on them for '27. It will be about the timing of the cash flows, and we'd expect it to get back to more normal given where we expect to be on our debt journey.

I see. So the timing of when you expect the cash flows is really more about debt paydown.

It's more about when the net cash flows are coming into the organization. But in addition to that, we've got debt paydown. So...

Is there anything in '27 that makes to kind of change again? Or is it sort of more of an annual thing now that more of your cash flow comes in the back half?

I think we'll see a more back half weight, but we won't have the debt repayments in 2027. We're scheduled to get down to around 40 this year. And so we'll be able to put that capital to work a little earlier.

That makes more sense. Maybe last question here on the guide, just kind of coming back to that, obviously, you've kind of guided to at least $30.25. Maybe help us understand what areas in your business you think potentially presents opportunities for upside as we think through the segments?

Yes. Maybe I'd point to just a couple of things. Obviously, our guide is our best view as we sit here today. On the Cigna Healthcare side, a big component of the picture is the medical cost trend and it's been elevated for multiple years now. And so if there's some -- I don't know if the right term is relief, but if it comes in better than we expected, then there's potential upside.

I'd say within the Evernorth space, both on the PBS side and the specialty side, it could be a story of volumes. We've got expectations. We think our data and the way that we're forecasting is pretty solid, but there's always a chance that there's some outperformance in volumes there. And biosimilar penetration is kind of the same -- along the same range. We've got an estimate, but there could be -- it could go a little faster than we think.

Okay. Great. Well, I think we're pretty much right on time here. So I want to thank Ann, Adam, thank you for joining us today. Thank you, everyone.

Thanks for having us.

Ladies and gentlemen, thank you for standing by for the Cigna Group's Fourth Quarter 2025 results review. [Operator Instructions] As a reminder, ladies and gentlemen, this conference, including the Q&A session, is being recorded.

We'll begin by turning the conference over to Ralph Giacobbe. Please go ahead.

Thanks. Good morning, everyone. Thanks 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 Group's Chairman and Chief Executive Officer; Brian Evanko, President and Chief Operating Officer; and Ann Dennison, Chief Financial Officer.

In our remarks today, David, Brian and Ann will cover a number of topics, including our fourth quarter and full year 2025 financial results and our financial outlook for 2026. Following their prepared remarks, David, Brian and Ann will be available for Q&A.

As noted in our earnings release, when describing our financial results, we use certain financial measures, including adjusted income from operations and adjusted revenues, which are not determined in accordance with accounting principles generally accepted in the United States, otherwise known as GAAP. A reconciliation of these measures to the most 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 the cignagroup.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 2026 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 to today's earnings release and in our most recent reports filed with the SEC.

Regarding our results in the fourth quarter, we recorded after-tax special item charges of $483 million or $1.82 per share. Details of the special items are included in our quarterly financial supplement. Additionally, please note that when we make prospective comments regarding financial performance, including our full year 2026 outlook, we will do so on a basis that includes the potential impact of future share repurchases and anticipated 2026 dividends.

With that, I'll turn the call over to David.

Thanks, Ralph. Good morning, everyone, and thanks for joining our call. 2025 was a pivotal year for our company as we delivered new innovations for the benefit of our customers, strengthen meaningful partnerships and extended strategic client relationships. Today, I'll briefly focus my comments on delivering our financial commitments for 2025, and how we are leading through a dynamic environment by evolving and advancing our business for the benefit of our customers, clients and partners. Then Brian will provide an update on our performance and our growth platforms and perspective on the year ahead. Then Ann will review additional details on our results and our 2016 outlook, and we'll take your questions.

So let's get started. In 2025, I'm pleased to report that the Cigna Group delivered full year adjusted revenue of $275 billion or 11% growth. Full year adjusted earnings per share of $29.84, a 9% increase, building on our multiyear track record of sustained earnings growth. We also took steps forward in improving our customer experience as evidenced by the increase in our customer Net Promoter Score year-over-year in each of our largest businesses. At the Cigna Group, we also continue to shape our portfolio in 2025, emphasizing businesses where we see clear opportunities to generate attractive sustainable growth. For example, we further expanded our specialty capabilities to serve hospitals and health systems in part with our new investment in Field Health Solutions. And we completed the sale of Sydney Healthcare's Medicare business earlier last year. We are well positioned to continue leading and growing in a rapidly changing environment.

To that end, I want to briefly comment on our global settlement with the Federal Trade Commission announced yesterday. The settlement is a comprehensive resolution of all matters brought by the FTC regarding pharmacy benefits business. It includes the industry-wide insulin lawsuit and ongoing investigations. To be clear here, the beneficiary of the settlement are our customers and patients. The settlement noted $7 billion in out-of-pocket cost relief over the next 10 years for the 100 million customers and patients we serve. The savings will be delivered through lower insulin prices and reduced cost for branded medications for consumers at the pharmacy counter. The settlement will also increase transparency for our customers and clients and strengthen our relationship further with community pharmacists. We were well positioned to execute on the terms of this settlement because of the new pharmacy benefit model that we began developing in the beginning of 2025 and announced in the third quarter of 2025. Our new model clearly positions us to achieve this comprehensive settlement. It enhances the value we provide to customers and clients, all while we continue to strengthen our position and deliver on our long-term shareholder commitments.

With the FTC matter now resolved and the additional clarity from the federal PBM reform legislation that passed earlier this week, we are squarely focused on driving affordability improvements and value for those we serve. We know health care affordability impacts everyone from individuals and families to employers and governmental organizations. At the Cigna Group, we are steadfast in our focus on leaning in to lower health care costs and expanding access to quality care and medications, but doing so requires confronting the underlying cost drivers, including both the demand and the supply side. Demand for health care in the United States is growing rapidly. Our population is aging and chronic conditions are increasing. Today, chronic disease and mental health conditions account for roughly 90% of total health care spending. Together, these forces drive heightened demand for health care services and as such increased costs.

Now relative to supply, in most industries when additional supply comes online, costs go down. However, in health care, costs are rising even as additional supply becomes available. Consider that since 2000, the cost of a hospital stay has increased more than 220%. And according to 2024 data, the median price of a new drug launch was over $370,000 compared to only $2,000 just 20 years ago. The organizations and professionals that supply and deliver costs, be they hospitals, doctors, pharmaceutical manufacturers and medical device companies are advancing significant innovations, but they are coming at an elevated costs. At the Cigna Group, we're moving forward with purpose and conviction counter these focuses.

Let me share a few ways of how we're doing that. First, our approach to investing in and shaping our portfolio guides us to collaborate rather than own physician practices or pursuing capital intensive care delivery infrastructure. This gives us more agility to offer new solutions and services that expand access, lower cost and focus on prevention and treatment adherence. Our transformative rebate-free pharmacy benefits model is one of those improved innovations for prescription drugs. Another example is our new clarity solution in Cigna Healthcare that Brian will talk about in a few moments.

Secondly, we are addressing affordability is by informing decisions more clearly on the location where care is provided as locations could significantly impact patient affordability, whether in a hospital, freestanding facility or a physician's office.

A third way is through meaningful partnerships and collaboration. For example, in the new Trump Rx site launches, Evernorth is the pharmacy partner to the site and will dispense EMD Serona treatment for fertility. This will make treatments more accessible for all Americans struggling to start or expand their families at the lowest available cash price. And we're helping providers focus on care by minimizing their administrative burden, for example, in prior authorization processes. Over the past year alone, we further reduced the number of prior authorizations by 15%, and going forward, we are partnering with the administration to further streamline the prior authorization process.

In the fourth way, we are driving affordabilities by leveraging competition and incurring the use of the most cost-effective solutions. Generics and biosimilar medications are important opportunities here. Today, for example, in the United States, approximately 90% of all prescriptions filled are generic, and they make up only 10% of the total pharmacy spend. As a result, the U.S. has some of the lowest generic prices in the world and highest uptake levels, reflecting what happens when robust competition is harnessed. We see similar promise with biosimilars and our company is already saving Americans money on the widely used brand-name medications such as HUMIRA and SOLAR, where we offer access to zero-dollar out-of-pocket offerings for our patients, saving them thousands of dollars each year.

Looking ahead in the coming years, there will be more than $100 billion of savings for the U.S. in the biosimilar space alone. At the Cigna Group, we will continue to make advancements in each of these areas in addition to the work we do day in, day out to support our customers, patients and our clients every day.

Now to summarize. Time and again, at the Cigna Group, we have demonstrated the ability to evolve to meet the needs of our stakeholders, something we've done over years and decades. Against the backdrop of a disrupted operating landscape in 2025, we delivered full year adjusted earnings per share of $29.84, and we returned over $5 billion to shareholders through dividends and share repurchase.

Looking ahead to 2026, our adjusted EPS outlook of at least $30.25 reinforced the sustained growth and strength of our company. We will also continue to make strategic investments in strengthening our capabilities and broadening our total addressable market profile, while we remain focused on harnessing the breadth of our capabilities across our organization for the evolving needs of those we serve.

With that, I'll turn the call over to Brian.

Thank you, David. Good morning, everyone. I'll start by outlining some highlights of our business performance in the fourth quarter and the full year. I will then highlight the key innovations we introduced in a dynamic environment and outline our view of the years ahead.

Our performance underscores the value we provide for those we serve through our three business platforms, providing multiple paths for sustainable growth, including our specialty and care services businesses within Evernorth, our pharmacy benefit services business also within Evernorth and Cigna Healthcare, our health benefits business. During the quarter, our Evernorth portfolio demonstrated continued performance. Starting in our Specialty & Care businesses, we delivered strong results with 14% adjusted revenue growth, reflecting the demand for our services, and we saw 13% year-over-year growth in the number of specialty scripts in 2025. This is supported by the shift to biosimilars and our industry-leading patient support in Accredo. Our portfolio shaping efforts have resulted in an expansion of our specialty capabilities to serve hospitals and health systems, in part through our investment in Shields Health Solutions that we announced in late 2025.

Next in Evernorth Pharmacy Benefit Services business, our fourth quarter and full year results reflect continued solid performance. We built on our track record of innovative pharmacy benefit solutions to meet market demands. This includes our suite of GLP-1 solutions. In 2025, we added EnreachRx, a new patient support model designed for pharmacies dispensing GLP-1 drugs committed to providing enhanced clinical services. We also expanded our patient assurance program to include these GLP-1 medicines, which sets caps on member out-of-pocket costs to improve predictability and affordability. And we are proud of our continued focus on service. We delivered a seamless January 1st implementation for new and existing clients, ensuring customers and patients have access to care when they need it. Overall, we're pleased to deliver another year of solid results across our Evernorth portfolio.

Now turning to Cigna Healthcare, our consultative approach and focus on affordability are driving strong overall performance. We delivered financial results that were slightly ahead of expectations. We maintained disciplined pricing while driving affordability and introducing or expanding differentiated clinical offerings. We're doing this in a number of ways, including encouraging customers to utilize lower cost generic and biosimilar medicines; optimizing sites of care between hospital facilities and lower cost alternatives and improving administrative processes for providers. We also continue to maintain a disciplined pricing stance. For sold business in the first quarter of 2026, our price increases are in excess of what we achieved for the comparable period in 2025. We expanded our suite of AI-powered digital tools to improve and personalized customer experiences. These include a provider matching tool to help customers find in-network providers based on their specific needs and preferences, and a real-time cost tracking tool to provide a simple breakdown of costs, both before and after clinician and specialist visits. We also launched new partnerships to expand our offerings. For example, we collaborated with Progeny and Karat to offer new coverage options for employers to support patients through their fertility journeys. And we announced an industry-first collaboration with head space to support the mental health of millions of Cigna Healthcare customers with exclusive digital features and content. We see partnerships like these as critical to building a more sustainable model for health care and further accelerating innovation for our customers.

Our performance across Cigna Healthcare underscores our focus on driving innovation, improving personalization, thoughtfully shaping our product portfolio and our execution orientation. As we look ahead over a multiyear horizon, we are focused on leading the changes needed in health care to better serve our customers and clients, resulting in improved affordability and access. To do this, we are taking bold actions, including investments in defining the future of health care.

Let me outline a few of these. First, we're focused on putting the customer at the center of everything we do through new innovations that are data-driven and tech forward. To do this, we are focused on personalizing the health care experience by leveraging and growing our digital and analytics capabilities. Already this year, we have seen a significant increase in digital registrations for our U.S. employer businesses and decreased call volumes. We are facilitating seamless interactions for customers based on their engagement preferences, whether that be mobile, web, text or fun, including chat options with AI virtual assistance and easy connectivity to our service agents for even more personalized support. Beyond this, we are finding new ways to utilize data and analytics, insights and digital tools to better identify patients who need help earlier, particularly those with complex and high-cost conditions. We continue to lead the way in transforming our models and capabilities for those we serve through meaningful innovations. In October of last year, we announced the transformation of our pharmacy benefits model to meet the demands of the market and improve both affordability and transparency for our customers and patients. As David mentioned, our new rebate free model will help people stay healthy and get the medications they need by lowering costs and supporting local pharmacies, so care is always within reach. We have received positive feedback about our new model from our broker partners clients and other stakeholders.

Moving ahead and following our recent settlement with the FTC, we are confident in the transformation of pharmacy benefits we are leading for the industry. In Cigna Healthcare, we are similarly driving step changes in our product offerings to create patient-centered solutions that simplify health care and ensuring we're rewarding outcomes rather than volume. One example is clarity our newest offering that we introduced in November, which puts customers and patients in control so they can focus on getting the care they need, designed with cost transparency available to customers at the time they need it. Clarity helps individuals manage their health with ease and saves clients up to 10% medical costs. And it has a simple co-pay-only structure. Clarity also has a single digital front door for all Cigna Healthcare customers integrating experiences for pharmacy, dental and supplemental health, and patients have access to our trusted national network without referrals, supported by clinically sound externally validated quality measures.

Finally, in our Specialty and Care Services business, our expanded suite of offerings has helped grow these businesses from around 25% of the company three years ago to around 35% this year, driven by high secular growth and our deliberate portfolio shaping to increase exposure in this highly attractive growth sector, and we see significant runway for additional growth in our specialty platforms in the future. This includes leveraging competition and the shift to more biosimilars and specialty generics with expected launches and uptake across other drug classes such as oncology, [indiscernible], autoimmune and inflammatory conditions. Guided by a clear mission and vision that prioritizes improving health care and keeping the customer at the center, paired with a partnership orientation and a portfolio intentionally shaped for sustained growth markets, we are leaning into the disruption necessary to drive industry transformation.

As I wrap up, I'd like to reflect on some bright spots for the quarter and the full year. Throughout 2025, we delivered through a dynamic environment. Revenues for the full year increased 11%, driven by specialty pharmacy growth and client relationships. We had a strong selling season in pharmacy benefit services with the retention rate over 97% for 2026. And we grew customers in our Select segment in Cigna Healthcare by 7%. We are a leading change in our industry from our commitments to better that we announced early last year, to our partnership with the administration on improving prior authorization to our announcements of affordable fertility drugs available through Trump Rx to our transformative new model for pharmacy benefits and our introduction of Clarity in Cigna Healthcare. Our mission, coupled with our capabilities, deep expertise and diverse portfolio of businesses positions us well to continue our track record of delivering for all stakeholders.

Now I'll turn it over to Ann.

Thank you, Brian, and good morning, everyone. Today, I'll review Cigna's fourth quarter and full year 2025 results, and I'll provide an outlook for 2026. We are pleased to deliver another strong year for the Cigna Group, reflecting focused execution across Evernorth and Cigna Healthcare with both segments achieving pretax adjusted earnings at or above the outlook we shared a year ago. For full year 2025, we delivered consolidated adjusted revenues of $275 billion, adjusted after-tax earnings of $8 billion and adjusted earnings per share of $29.84.

Now turning to our segment results. I'll start with Evernorth. 2025 marked another year of growth in Evernorth and the introduction of an industry-leading innovation and pharmacy benefit services as we advance our more simple, predictable and transparent rebate remodel. We also advanced our Specialty and Care Services capabilities through a strategic investment in Shields Health solutions as we build on our market-leading position and enhance our offerings in one of the largest and fastest-growing areas in health care. Fourth quarter revenues grew to $63.1 billion, and pretax adjusted earnings grew to $2.2 billion, in line with expectations. Our Specialty and Care Services business delivered strong growth, generating $26.7 billion in revenue, an increase of 14% year-over-year and $1 billion in adjusted earnings. This performance reflects sustained momentum in our fastest-growing business, driven by robust specialty volumes and rising biosimilar use, which continues to generate meaningful savings for our patients and clients. Our pharmacy benefit services business delivered $36.3 billion in revenue and $1.2 billion in adjusted earnings reflecting the impact of our strategic investments, including initiatives to enhance patient experience. Overall, the fourth quarter capped another year of growth for Evernorth. The underlying strength across our Evernorth businesses reinforces our confidence in making deliberate near-term investments to transform our pharmacy benefit services model, positioning us well for sustained long-term value creation.

Turning to Cigna Healthcare. In 2025, Cigna Healthcare delivered strong results above our original expectations in a dynamic environment. This performance underscores the strength and resilience of our purposely constructed portfolio, including the divestiture of our Medicare businesses, which positions us to navigate volatility and drive durable growth. For fourth quarter 2025, Cigna Healthcare delivered adjusted revenues of $11.2 billion and pretax adjusted earnings of $734 million. Adjusted earnings slightly exceeded expectations as favorable net investment income more than offset modestly higher medical costs. The higher medical costs equated to approximately 60 basis points of MCR or about $50 million without notable impact to any one part of the portfolio. Relative to our stop-loss products, the full year MCR was slightly higher in 2025 compared to 2024, consistent with what we expected and communicated at the beginning of the year, and we remain on track with our margin improvement plan. Overall, we're pleased with Cigna Healthcare's performance in 2025. Looking ahead, we remain focused on driving greater affordability and value for the patients and clients we serve while continuing to execute with discipline against our financial targets.

Now turning to our 2026 outlook. We expect full year 2026 consolidated adjusted revenues of approximately $280 billion, and we expect full year 2026 consolidated adjusted income from operations of at least $30.25 per share. Considering earnings seasonality, we expect first quarter EPS to be slightly above 25% of our full year guidance.

Now turning to our 2026 outlook for each of our segments. In Evernorth, we expect full year 2026 adjusted earnings of at least $6.9 billion. As we discussed previously, we expect investment spending to build the infrastructure required for our transformative rebate remodel to commence in 2026, with this spend more back half weighted. As a result, we expect Evernorth's first half earnings to be higher than the historical pattern with the first quarter representing over 20% of full year earnings. For Cigna Healthcare, we expect full year 2026 adjusted earnings of at least $4.5 billion. Within Cigna Healthcare, we expect earnings seasonality to be consistent with prior years with the first quarter representing over 30% of our full year adjusted earnings expectations for the business. Assumptions underlying our 2026 outlook for Cigna Healthcare include a medical care ratio in the range of 83.7% to 84.7%, incorporating the pricing actions taken across stop loss, and individual exchange businesses as well as the assumption of a cost trend environment that remained elevated. We expect the first quarter 2026 medical care ratio to be below 81%, reflecting typical seasonality. We expect approximately 18.1 million total medical customers at year-end, including growth in our middle select and international markets offset by lower membership in our national accounts and individual exchange business.

For the enterprise, we project an adjusted SG&A ratio of approximately 5% for 2026, consistent with the 2025 level, reflecting both the investments to advance our pharmacy benefit services model and continued improvements in operating efficiency. We expect the consolidated adjusted tax rate to be approximately 19%.

Now moving to our 2025 capital management position and 2026 capital outlook. Our fourth quarter cash flow was strong, and we finished the full year by delivering $9.6 billion of cash flow from operations. In 2025, we repurchased 11.9 million shares of common stock for approximately $3.6 billion and returned $1.6 billion to shareholders via dividends. We also improved our debt to capitalization ratio to 43% during 2025, including an improvement of 190 basis points in the fourth quarter.

Now framing our 2026 capital outlook. We expect to deliver approximately $9 billion of cash flow from operations. As previously noted and consistent with 2025, we expect the majority of operating cash flow to be realized in the second half. Our capital deployment priorities remain consistent with our long-term framework. We expect to deploy approximately $1.3 billion to capital expenditures, and we expect to deploy approximately $1.6 billion to shareholder dividends, reflecting our increased quarterly dividend of $1.56 per share. Our guidance assumes full year weighted average shares outstanding to be in the range of 261 million to 265 million shares. And during 2026, we expect to continue progressing towards our long-term debt to capitalization ratio of approximately 40%.

Now to close. As we move into 2026 and beyond, we remain confident in the strength and the resilience of our enterprise. Our disciplined execution, balance portfolio and strategic investments to drive innovation, affordability and an enhanced customer and patient experience, all position us well to deliver differentiated value for our customers, clients and shareholders over the long term. We are confident in our ability to deliver full year 2026 adjusted earnings of at least $30.25 per share, and our ability to deliver attractive long-term EPS growth.

And with that, we'll turn it over to the operator for the Q&A portion of the call.

[Operator Instructions] Our first question comes from Lisa Neil with JPMorgan -- apologize, Lisa Gill.

David, I fee like we've been waiting for a long time for this PBM legislation to finally pass it's finally passed. You've put behind you the FTC suit. Can we talk about a few things. The first -- the change in economics. You talked about this with the new plan in October. But now that everything is kind of settled in place, we've got legislation, et cetera. Can you spend a few minutes talking about the margin profile of what we would expect in the steady state for the PBM? And then secondly, one of the things that stood out to me in the FTC settlement was the moving of the GPO back to the U.S. from Switzerland. I want to understand what that means to the tax rate. My understanding is that the tax rate over in Switzerland is about 15%. So when I think about [ SN ] coming back, what's the financial implication for that as well.

Good morning, Lisa, thanks for your comments and your question. So first, pulling back up, we've been saying for some time that the pharmacy services space would go through a clearing event, be it driven by market innovation, legislation or regulation. And when you step back, many of those forces converge this week. And the clarity of direction that we established back in 2025 with the work we started in early 2025 and announced in the third quarter of 2025 with our new innovative model from our point of view, is directly aligned. So to the first part of your question, at a macro level, as we said in the third quarter of last year, we believe the margin profile will remain similar. We have significant experience with a variety of programs today with the diverse population we serve, be it fee-based full pass-through, the continued innovation we drive with our clinical programs and services that we are able to offer that from a big picture standpoint, we believe the margin profile will be similar and therefore, we believe the underlying growth algorithm for the pharmacy benefit services portion of our portfolio will remain intact to be similar as we get through this innovation. And importantly, before I come to your tax question, it's important to really underscore the underpinnings of our innovation. First and foremost, it starts with a customer-first orientation in its design. It's therefore built to ensure that we are capable of delivering the lowest out-of-pocket cost for the consumer each and every time they consume a pharmaceutical at the altar most likely through their benefit program in the vast majority of cases, that's the instance and the unique cases where it could be a cash pay program or a direct program, et cetera, we have the ability to be able to support that additionally meaningfully expanding the support programs for independent local world pharmacies. And then lastly, as we've discussed, it's built on a more modern, no rebate, no spread framework that gives all visibility to employers on a fee-based transparent environment, and ultimately provide you shareholders more visibility of the sustainability relative to it. So big picture, no change in overall margin profile, and therefore, no change in the growth algorithm over time for pharmacy benefit services business. As it relates to the second part of your question, the Ascent GPO has been and continues to be an important tool to improving affordability for customers and patients. We will move capabilities to the United States, bringing them closer to our U.S. operations. We remain confident in the -- as I said before, the growth algorithm of the business. At the macro level, you could think about an outside impact to the effective tax rate of our organization of up to 1% over time because there's a phase in here if unmitigated. So if you want to put a box around that, you can think about a maximum impact of 1% in the future if mitigated, therefore, given the strong performance of our portfolio and our diverse enterprise, we see that as totally manageable even at the outside parameters of that against our long-term earnings growth algorithm of 10% to 14%. Thanks for your question.

Our next question comes from Scott Fidel with Goldman Sachs.

Just wanted to follow up on Lisa's and then ask a follow-up around Brian's comments on the new pricing model with the customer. So the first question, just following up on Lisa's question is just, it really does feel like there's been a real sea change in collection and just the amount of activity and developments that actually occurred around sort of moving the premium pricing model forward. And just curious from your perspective is, do you feel like at this point now, you've largely fully aligned your PBM model with how the regulators, with how the policymakers have been really pushing the industry to adapt to, or are there still some sort of regulatory battles, residual battles still ahead? And then I wanted to just ask Brian around the premium clients in terms of moving to the new pricing model, just the traction that you're seeing there in terms of sort of your updated view on the ramp that you're expecting in terms of 26 to 28 the percentage of clients that you expect to move on to the pricing model.

Scott, it's David. Let me take the first part of your question, and I'll transition to Brian for the second part. First, just contextually, it's important to note we are proud of the significant value that has been over a long period of time to the people we have the privilege of serving, our customers across the United States. And by way of context there, fully 80% of the Express Scripts customers have less than $250 out of pocket over the course of a full year. I'm going to come back to that in a moment. And as I noted, through the good work of the pharmacy benefit services industry over a long period of time, 90% of all drugs consumed in America are generic, and they make up just over 10% of the total cost equation but 10% of brand, which make up almost 90% of the cost equation. That's creating undue pressure in force on everybody in the model today, including out-of-pocket dislocation for consumers. So when you come back to our model, we are confident that our model is built. The new innovation is built through customer first, no rebate, no spread, fully transparent fee-based model, where we step into the advocacy role for the consumer at point of consumption of a pharmaceutical each and every time at the counter to dynamically shop and make sure they get the lowest out-of-pocket costs. So when you look at any of the legislation or regulation, it's been oriented around improving affordability and predictability, harnessing, ultimately, transparency and expanding value for ultimately the consumers, along with the clients. Our innovation squarely goes in that direction, and we are excited and confident to lead the way for the industry. I'll transition to Brian for the second part of your question.

Thanks, David. Morning, Scott. As it relates to the adoption rates and the pricing model, et cetera, consistent with what we talked about in the third quarter call, the entire Cigna Healthcare fully insured book will be adopting this new model in 2027, and we expect at least 50% of our Evernorth business will adopt the model by year-end 2028. Early feedback from clients brokers and other external stakeholders have been positive to date. And I think importantly, coming back to link Lisa's question and yours, the core value creators in both our legacy models, and our new rebate free model really remain the same. If you think about securing better unit pricing for prescription drugs, administering benefits for plan sponsors and supporting patients with clinical safety checks and advanced clinical programs. Those three core value creators are the same in the legacy model as they are in the new model that we've introduced. The primary difference is the way in which we're compensated. So there's two primary ways will be paid in the future in this model. The first is a core admin fee that will be per member per script, delinked from the price of the drug. That will grow inflation over time. And then the second category be for clinical programs and other innovations that we bring to market, and we expect to take risk on this portion of the compensation. But in aggregate, as David said earlier, we expect to achieve a comparable level of profitability between the legacy model and the new model, although the sources of profit will evolve that land.

Our next question comes from Charles Rhyee with TD Cowen.

First one, just on clarification is just -- I think, Brian, you kind of mentioned it. With the settlement -- the timing of the settlement requirements, is that aligned with the launch of the new rebate free model is the first just sort of clarification question. But the second -- my second question really is more, obviously, your all these settlement agreements are related to the standard -- to provide standard offering, right, which largely aligns it feels like with the new model that you're launching by 2028. I guess the question is, to the extent that clients don't take this new offering, what is the responsibility for Cigna or Evernorth in this case to push the new standard offers so that these requirements are met. And if clients don't choose to take the new offering. Is there any sort of liability to Cigna down the road? And in particular, I'm kind of looking at, for example, ensuring members out-of-pocket expenses are lowest net cost. But if an employer doesn't choose that new option or if the employer chooses to maybe increase a coinsurance amount or deductible, is there any kind of does any kind of responsibility fall by to Cigna?

Charles, good morning. It's David. Let me take the second part of your question, and I'll tack team with Brian on that as well as the first part of your question to pick up on. So a few important points here. First, macro we have, and we continue to believe in offering choice to the marketplace. And we serve a diverse number of clients from governmental agencies to health plans, to employer clients, et cetera. Two, as Brian noted, we will adopt this innovation January 1, 2027 for the Cigna Healthcare guaranteed cost book of business, where Cigna is the purchaser. So we will leave in the accelerated adoption. And third, we expect to see significant adoption in 2028, as Brian mentioned before. Second, it will be our standard offering. It will be our lead offering in 2028, and that is congruent with the settlement and the direction. Third, there is no liability that we assume if the adoption rate is above or below that, we will lead the market. We will support this with marketing dollars because we are convicted and believe that this is the future of pharmacy benefit services. for the benefit of consumers as well as clients as well as community pharmacists. So our conviction we will lean in and support the aggressive adoption of this. But choice will still be in the marketplace. We will still be able to afford -- enable solutions and forge solutions be the rebate, rebate pass-through or otherwise as the market goes through its transitional process and ultimately this model on a go-forward basis. Brian, anything to add to that or to the first part of...

That's a pretty comprehensive answer, David, but just a few additional comments, Charles. So our launch plan from the standpoint of our new rebate-free model is unchanged based upon the FTC agreement that we reached this week. So we'll continue with the same milestone, the same expectations. And importantly, as David made reference to earlier, inherent in our new model is we call our price Assure technology, which guarantees patients the lowest possible price on the drug when they get it filled. So whether that's the price we've negotiated with drug manufacturers whether it's a cash pay alternative, whether it's their co-pay, whatever the lowest possible prices, we're guaranteeing in the new model of the patient will get that. And so that enables us to meet the spirit of the FTC's goals as well to drive lower patient out-of-pocket and to the point of what else could be a little bit different. Lisa's question earlier, the move of our GPO capabilities from Switzerland or the U.S. unrelated to the new rebate-free model. So there's some elements of the FTC agreement that are unrelated to it, but the launch plan for our rebate-free model is unchanged as a result of the agreement.

Our next question comes from Kevin Fischbeck with Bank of America.

I'm a little bit surprised that the MLR in 2026 isn't expected to make any progress given exchanges should be repriced and smaller and stop loss. It sounds like you're repricing that again, getting generally speaking about pricing this year than last year. Why is that? And then I guess if you could just maybe give us a sense on the current business mix, what the right MLR to think about is when the business is fully repriced in the future?

Kevin, so I'll start by just reminding you what I mentioned in my prepared remarks, our 2026 MCR outlook incorporates the pricing actions we've taken across stock loss and the individual exchange businesses as well as the assumption that the cost trend environment remains elevated. So when thinking about the walk -- the MCR walk from '25 to '26, I'd point to -- two things that reduce the MCR, and two things that increase it. With respect to the reductions within stop loss, pricing is tracking in line with expectations and we've achieved rate increases consistent with our targets for improvement in 2026. And then the second is for our individual business, we've repriced for margin improvement. So those are the two things that will reduce MCR going into '26. Items that increase the MCR on a comparative basis. If you recall that the 2025 MCR benefited from several onetime items in our individual business, both of which impact the jump-off point for the year and tempers the year-over-year MCR improvement. And beyond those items, there are mix dynamics to consider as well. And lastly, I do sort of overall, our assumptions incorporate appropriate prudence given the continued elevated cost environment. So summarize, our MCR outlook incorporates stop-loss and due to individual pricing actions, onetime impact to '25 as well mix considerations impact that year-over-year view. And we continue to assume an elevated cost environment and appropriate imprudent. And for your question around the MCR, I'd point you to to the outlook that we provided in terms of the range of where we expect to end up for 2026.

Our next question comes from Justin Lake with Wolfe Research.

I wanted to ask a couple of more PBM questions. As you look out to 2027, it certainly seems like you don't business transitions associated with the FTC settlement, the legislation would be a headwind to earnings, but wanted to confirm that is the case, and you expect 2027 PBM's earnings growth at this business to be in line with your long-term algorithm. And then just from an accounting perspective, is there any changes to PBM revenue recognition here from all these business model changes effectively the move away from spread pricing, rebate guarantees towards a fee-based model, will in still be able to book the total pharmacy spending as revenue? Or would it move to kind of booking fee revenues similar to ASO on the medical side?

Good morning, Justin, it's Brian. On the first part of your question. At this point in time, the FTC agreement will not impact our 2017 financial outlook. Many of the agreements and commitments are multiyear in nature. As we talked about earlier, and as David said, our long-term growth algorithm for EBS remains intact as we move through the transitional period here. As we talked about on the third quarter call, we do expect 2026 and 2027 to have investment-related costs as we build out technology and infrastructure to support our new rebate-free model. So that's really the only thing I'd have you think about as it relates to 2027 in terms of the PBS outlook. On the revenue recognition question, at this point in time, we do not expect there to be changes in the way that our revenue is being recognized in the PBS segment even with the transition to a fee-based model as opposed to spread or rebate-oriented model that we have today. So we'll refine that over time and certainly can take that offline with you. We did not expect a change in the denominator and the margin profile.

Our next question comes from Erin Wright with Morgan Stanley.

I know there's a lot of focus on the PBM. But can you talk about the specialty business. You mentioned some of the strong organic growth there. Can you unpack a little bit some of the key drivers there, what you're anticipating in 2026. Any other implications from some of the dynamics at the PBM side as well, but also biosimilar pipeline, and as we head into 2026, how you're thinking about that?

Good morning, Erin, it's Brian. So as we mentioned in our prepared comments, really pleased with the momentum of the Specialty business 14% and top line growth and attractive earnings contributions alongside of that. And we've talked about before with you, this is already a $400 billion-plus addressable market growing at a high single-digit secular growth rate, and we're really well positioned to capitalize that on that over the longer run. And we certainly saw the dynamics emerge throughout 2025. So the full year, we had 13% growth in prescriptions. Higher rate of growth in our Medicare book of business, but also strong growth in the commercial employer and the Medicaid portfolio. And our Evernorth business is really well positioned to capitalize on each of those different payer types. We continue to expect long-term average annual income growth of 8% to 12% in this business, benefiting from some of these strong secular tailwinds. A few specific TRCs or cost categories, I'd highlight that were particularly strong growers, include inflammatory asthma and allergy, those were -- those generated a good bit of the year-over-year growth in the specialty space. And as it relates to biosimilars, we're really pleased to see the building momentum across the United States, really HUMIRA, the past two years, becoming mainstream was a great win for the market. And as David said earlier, we expect another $100 billion of Specialty drug spend to be subject to competition from biosimilars and generics by 2030. Each of these biosimilars have a slightly different adoption rate based on factors such as interchangeability, dosage levels, branded alternatives and other dimensions. But we've, as you know, introduced a zero-dollar patient out-of-pocket for both HUMIRA and STELARA. And the HUMIRA penetration in 2025 ended up representing the vast majority of eligible scripts. So that's clearly been a success story for American Healthcare from the standpoint of patients getting significant savings finance years, whether those be employers or health plans getting the benefit of the savings on these biosimilars, and we look forward to continue driving savings for patients in the future in the biosimilar and specialty generics space. So to kind of wrap this up space we're really excited about. It's 35% of the company's income now. That percentage will continue to grow in the future as we execute.

Our next question comes from A.J. Rice with UBS.

First, just a point of clarification to the previous comments. You guys gave the outlook for the new rebate-free model. And with that I mean for growth when you talked about third quarter, you haven't really changed that today, but you've obviously had FTC settlement and other things, where those -- I know those don't happen overnight, were those largely contemplated when you made your comments about the outlook in the third quarter. And then the other thing I was wondering on your deals with manufacturers on the pharmacy side, do those need to be significantly renegotiated? How much of an unknown is that over the next few years? And do you envision formulary changes, significant or any other things we should be thinking about from the cost side of the pharmacy business.

A.J., good morning. It's David. A few parts to your question there. First, on the -- your opening portion of your question. You're correct. Our outlook or the '26 time frame and our outlook for the direction of our new pharmacy benefit innovation remains consistent, both the adoption target for 27, the adoption target for '28, and the overall margin profile. Two, as I noted earlier, we began working on that in early 2025, the architecture of it, the design of it, et cetera, and we announced it in October, as you recall, of $25 million and the architecture of what we've built is quite congruent with where the regulatory environment was heading and was likely to head. So when you step back, you can look at the legislative environment or the regulatory environment, and say, what is the focus? The focus here is on increased transparency. The focus is on an environment customer first and tries to optimize the customers out-of-pocket costs and improve the customers' affordability. It's one that is more performance-oriented in some examples, I'll focus on the critical role of independent pharmacists in rural locations, et cetera, all that was contemplated in our design that we began approximately a year ago. So therefore, no change in the direction as a result of the settlement. No change in our direction as a result of what we saw in the legislation in the past this week. On the second part of your question, there's work that sits in front of us to do, as Brian talked about, in the third quarter call and we referenced briefly here in terms of the build-out of the capabilities. But it is very familiar work to us and for our organization in terms of whether it's the technology work that needs to be enhanced amplifying capabilities that we're already using for the benefit of consumer pricing at point of consumption today or the work directly back with the manufacturers in terms of the restructuring of the economic arrangements that are aligned with this more transparent model on a go-forward basis. And your final question is will there be formulary changes. The formulary is a bit fluid. It's governed by clinical efficacy and comparative effectiveness. So clinical advocacy around the notion of the clinical impact of like-for-like drugs when they're similar, that it moves on to comparative effectiveness, which is the economics to generate that, but always led from a clinical standpoint with independent oversight. And the fluid nature of that will transpire. But my closing comment would be, I would not expect that the transitional model to the future, it will be a direct correlation to a formulary change the formulary who will continue to be guided by the proper governance of clinical efficacy first and then comparative effectiveness, optimizing the total cost structure. So taking it all in, again, we could not be more pleased with the direction that we have set for the industry around the transparent customer-centric, rebate-free fee based model, and the ability to secure a broad closure of issues, both from a regulatory standpoint and clarity from a legislative standpoint. A.J., thanks for the question.

Our next question comes from Stephen Baxter with Wells Fargo.

I was hoping you could maybe expand a little bit more on the health care medical membership outlook that you gave. It seems like we're seeing a bit more of an outsized shift into ASO funding models based on some of the other reports Series, maybe that's the higher cost environment. So I was hoping you could expand a little bit on what you're seeing there, whether you might see more outsized growth in select this year? And then just broadly, how you're thinking about in-group enrollment trends given some of the uncertainty in the macro right now?

Good morning, Stephen, it's Brian. So as it relates to the Cigna Healthcare membership outlook, as you saw in the press release, we expect flat year-over-year at about 18.1 million lives. And really, you can think of that big picture is we expect growth in our U.S. employer and international health businesses, offset by a decline in individual exchange customers. Within the U.S. employer portfolio, we expect to see growth in both our select and middle market subsegments, reflecting the continued strength of the consultative model along with our integrated medical, pharmacy and behavioral offerings, plus our focus on affordability for these employers. I would not expect an outsized year of growth to your question on select necessarily, but we do expect growth in that space in 2026. And that growth in selected middle market is partially offset by some decline in national accounts customers in 2026, similar to what we signaled to you previously. Within the individual exchange business, we expect to end 2026 with fewer than 300,000 customers, reflecting another year where we prioritized margin over growth. So again, the net effect of all of this is membership that's approximately flat, although we anticipate an attractive year of earnings growth within Cigna Healthcare. As it relates to the funding mix, we expect our group risk business to be stable for 2026 compared to 2025. So think of around 2.2 million lives, which, again, reflects our disciplined pricing posture. And as we talked about in prior settings, our select segment mix today is roughly 2/3 self-funded, and our net growth in Select has been coming from ASO and level-funded style solutions in recent years. And as a reminder, we're not active in the under 50 regulated small group markets. So our commercial group risk business here is essentially all large group in nature. In group enrollment trends, we are not seeing anything out of the ordinary. Obviously, we continue to monitor economic data unemployment data. But to date, we have not seen anything out of the ordinary. Our 2026 outlook reflects our current view of what the economy will do.

And this question comes from Jason Cassorla with Guggenheim.

I wanted to ask, especially in care for 2026. I just wanted to confirm, are you still anticipating AOI growth at the higher end of your 8% to 12% target offer '26. And then can you help spike out what the implied AOI growth would be when excluding the income attribution from the Shield investment? Just maybe like more core basis, growth would be helpful.

Sure. Jason. So for Specialty and Care, we expect earnings to grow towards the high end of the long-term growth rate, reflecting both strong fundamentals and the contribution from the shales investment. We're really pleased with what we saw in 2025 overall for Specialty & Care. Our expectations for 2026 remain consistent with what we shared coming out of the third quarter. We haven't shared the details specifically around child is built into our expectations, but that takes us to the high end of the range.

Our last question comes from Andrew Mok with Barclays.

The operating cash flow and CapEx guidance implies less than 80% free cash flow conversion on your pretax income, which is below recent history and lower sequentially. So can you walk us through the drivers of that pressure and comment on the expected impact of the new rebate-free model on working capital?

I'll start with the cash flow expectation. So we were really pleased with $9.6 billion for this year coming out. And as I said in my prepared remarks, we do expect a dynamic of higher cash flow or more cash flow in the back half of the year next year. When stepping back and looking at our 2026 cash flow expectations, that -- the decline to the $9 billion that we're guiding to next year is roughly $600 million less than what we thought in 2025. That primarily reflects the lower contribution from the PBS business from our pharmacy benefit services business. And really, that includes the impact of large client renewals and some of the investments that we're making in 2026.

And Andrew, the rebate-free model will not impact the '26 cash flow outlook. And as we get closer to '27 to '28, we can square that up for you a bit in terms of reconciling how that moves year-over-year.

I will now turn the call over to David Cordani for closing remarks.

First and foremost, thank you for your questions and your time today. I just want to reiterate the items. First, with our momentum, we are confident we will deliver on our adjusted EPS outlook of at least $30.25 for 2026. Important to note in the context of a very dynamic environment in 2025, we delivered competitively attractive results, and I'm proud of how our team works tirelessly each and every day for the benefit of those we serve, where we work to know our customers help them by delivering personalized solutions and support programs for the unique needs and working every day to make it easier to access affordable care. We look forward to our future conversations. Thanks, and have a good day.

Ladies and gentlemen, this concludes the Cigna Group's fourth quarter 2025 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 866-405-7290 or 203-369-0603. There is no pass code required for this replay. Thank you for participating. You will now disconnect.

Hi, everyone. I'm A.J. Rice, the health care service analyst at UBS, and we're very pleased to have next up in this room, Cigna Group. We've got Ann Dennison, Chief Financial Officer of Cigna; and Adam Kautzner, President of Evernorth Care Management and Express Scripts. I think Ann is going to make a few opening comments, and I'll let her do that, and then we'll do some Q&A.

Great. Thanks, A.J. Thanks for having us. And everyone, thanks for joining. I know we're at the -- sort of towards the tail end of the conference. So I appreciate you being here. I'm just going to say a couple of things before we jump in. So one, to start, we've been really pleased with our performance this year, especially coming out of the third quarter with strong performance.

And then also being able to reaffirm our full year EPS guidance of at least $29.60 again coming out of this quarter. We've been operating in a very challenging and dynamic time. Despite that, we've been able to execute and also invest for the future. And so I'd point to 2 things there. One, our investment in Shield, so an investment in a company and in a space, the specialty space that's growing 17% to 19% on a big TAM. So really excited about that.

We're also really excited about a couple of weeks ago, we announced the new transformative rebate-free model, and Adam and I are really excited to be here today to talk to you all about that and get into some more depth there. The last thing I'd say is just given where the stock is, we don't believe that the stock price reflects the true value of our long-term proposition and our ability to grow.

And so as I think about capital deployment coming out of this year and into next year, I'm going to be really focused about being opportunistic on the stock repurchase side of things, while at the same time, using our capital in the appropriate ways, but also following our deleveraging plan. So excited to think about it a little bit differently given the opportunity in front of us. So that was all I wanted to say to start...

That's great. I appreciate that, Ann. So why don't we jump right in to what you just mentioned, the transition to a rebate free PBM model has created quite a stir in the market and the industry. Can you talk about the decision to make this move and why it made sense to do it now versus a more gradual approach?

Sure, A.J. I'll take that. Good morning, everyone. So we're thrilled to be able to bring this new model to the industry. It's unlike anything that has been done in the pharmacy benefit space in decades. We're reimagining the pharmacy benefit. How we're going to do that? One is, yes, it's going to be a rebate-free model, which means for the consumer, an upfront discount where they immediately receive the full value of what we negotiate with the drug manufacturer. It's one big benefit.

Another big benefit is we are going to be enhancing our system to where regardless of where the lowest price may exist. Normally, that's within the ecosystem of what we negotiate at Express Scripts, but it also could be a direct-to-consumer price that a manufacturer may offer or it could be within the cash pay market for a drug that may not be covered under the benefit. We're going to seamlessly be able to pull that lowest price. We're going to be able to have it still go through our ecosystem to apply all the safety and quality checks and we'll be able to immediately apply it to the patient's deductible.

So for the consumer, there are some big benefits here. In addition, we're going to be able to reimburse pharmacies, the community pharmacies at their acquisition plus a dispense fee. So we're going to be able to help to solve the issue around community pharmacies in rural and urban areas from an access-to-care perspective. And we're going to do all of this with a simplified administrative fee that we are charging to our clients that will be delinked from the price of the drug. So very different from today, that will be delinked from that price.

It will be a flat administrative fee to simplify the pharmacy model. Thus far, feedback, especially from President Trump administration, Secretary Kennedy administrator has been very positive as well as other members on Capitol Hill about us and our forward-thinking model here that's fully transparent and delivering real value to the consumers, but also being able to provide value to our clients. That is very different than a point-of-sale rebate model, which is retrospective, and there's reconciliation that occurs in those types of models and their estimates and the complexity within a point-of-sale model.

This is an upfront direct discount that's going to be available to our -- to consumers while also keeping our clients' costs in check. So this model will be durable, sustainable and it future-proofs us and will be a competitive advantage for us for 2028 and beyond.

I think one of the arguments against moving away from the rebate model was the impact to premiums on the health plan side given employers use the rebates to keep overall premiums down. How are you assessing this dynamic when you speak to clients and keeping that desire to keep the premiums down?

A.J., this model, we believe will be premium neutral for our clients compared to the existing model that exists. And it is important to point out, although we are going to be moving on our new standard will be this new model, we are still going to continue to support a rebate model for the foreseeable future. So we will continue to have those options.

For this specific model, though, we will, one, be able to provide for the consumer dramatic value on these branded drugs. There are a lot of branded drugs today, which are not ever picked up because of the cost. By reducing that barrier, patients are able to access the medications, refill the medications on time, which will lower total cost of care, bringing cost down. Secondly, drug manufacturers today do try to offset many patients that are in the deductible or high coinsurance phase and they buy down the cost of those drugs at the pharmacy counter.

We are now going to be able to effectively reduce the need for those types of programs. That creates another opportunity for us to extract value from pharmaceutical manufacturers and bring that back into the plans to help offset those premiums. Even with all those pieces, we will continue to be able to offer premium-neutral options to our clients to allow them to make those decisions.

On the other side, you just sort of mentioned that pharma manufacturers have suggested they'd love to move to some model like this for some time. sometimes be careful what you wish for. But on that same token, how are they -- how are the pharma manufacturers responding to this announcement and the new model?

The conversations so far have gone really well. They've been productive. Manufacturers have been receptive to this new model. You're right. Many of them have asked for what if the rebate model were to go away. This is the answer to that of this new rebate-free upfront discount type of model. And there is some alignment there of today, they do spend a lot of money in buying down patients that are in those higher cost deductible phases, and this alleviates the need for that and provides us with having a new conversation with them on how we're going to be able to better provide that value back to the consumers that need it most as well as to their clients.

So overall, I'd say it's been very positive and productive. And keep in mind, we are going to be recontracting across the entire pharmaceutical landscape with every manufacturer with this new model and this new type of way that we're going to be doing business with them.

And just to clarify that. So the time frame on those recontracting for the new model, is that in place? Are you doing that now? Is that something as you move toward '28, you'll do more of that? How do we think about the timing on those?

Sure. So the timing is for 2027, we'll be moving to the rebate-free model for Cigna Healthcare's fully insured book. For 2028, this will be available to the rest of the Express Scripts book of business. So that's where we'll be contracting with manufacturers. So we have these next call it, 2 years, where we're going to be transitioning to this new way of contracting. We're going to be making those short-term investments to be able to build all the different pipes that we're going to need for this new type of model to have the good data analytics for the new type of contracting that we'll have.

But remember also, we're going to continue to also have the core type of contracting around the value-based solutions that we have within our SafeGuardRx portfolio today, the other clinical services that we're able to contract with manufacturers on. So we expect this to be a complement to those within that portfolio while still supporting a rebate contracting model, too.

So one of the questions we've gotten asked is if you got this dual track basis, the part of the business being traditional rebate model, the other, the net price model, how should we think about how that affects your negotiations and the interplay with pharmacy given the rebates will be less of a factor in one model versus the other. Does that complicate the negotiations as you try to work through all that with this dual track?

We don't expect for it to complicate it at all. Today, we contract with manufacturers across, as I mentioned, many different ways, value-based being one certain example beyond rebates. So we expect to be able to fully support both types of models, and we'll be able to continue to extract market-leading rates, not only in the existing system, but also with this new model. And actually, I think this will become a competitive advantage for us to have this type of forward-thinking new model that's going to be available in the market from a client perspective.

Okay. And you did talk about absorbing incremental investments to put all of this in place in '26 and '27 as you make that transition to the new model. We understand that there's expenses associated with the dual track aspect, too. Is there a substantial incremental cost burden associated with this? And how do we think about that?

Yes, I can take that one. And maybe to bring it back up to what we said coming out of third quarter earnings. So we expect some pressure on the PBS line next year. Part of that pressure is the recontracting and the new client renewals and extensions that we're doing. And then part of it is the investments that we're going to make around this transformative rebate premodel. More than half of it is the first thing.

So for the piece that's related to the investments we're going to be making, and I think it's really important to sort of come back to -- as Adam has talked about this in terms of transforming the market here, we are not just tweaking an existing model. We are doing something holistically different than what we've done before. And so just for context, right, 2,000 clients, 100 million lives in this space. And so we are building and investing in an infrastructure that's going to support that under a new model than what exists today.

So as I think about what are the things in that category that we are going to be spending on. So probably technology is the largest, the first thing I'd mention. So all of our systems are designed to support a rebate model. We are going to have to invest in those over the next 2 years, so in '26 and '27 to be able to have the dual model in place. So that is one. The next 2 I'd sort of put in the same category is maybe a mix of 3 things.

So process optimization, operations optimization and also all of the recontracting work. Adam talked about the manufacturers, but we also have to recontract with all of our clients throughout this process. So there'll be investments across those categories. And then finally, I'd say a big important step here is having the right data so we can optimize our model.

So investing in data and analytics tools that help us find the right places to expand opportunities with clients, the right places to innovate. And so as we think about '26 and '27, you could think about roughly equal amounts of investment across those 2 years to stand up everything that I just described.

And along the same lines, following up on that, it sounds like in '28, there would be some dissipation of this spending level. Can you talk about -- of that investment, how much is sort of a new run rate of investment? And should we get a little tailwind in '28 from that?

Yes. I mean I'd expect sort of the bulk of the spend is going to be '26 and '27 as we stand up. As we talked about in earnings, our goal is through 2028 to have 50% of our clients on this standard new model. And so we'll look to optimize our processes along the way. We're at a sort of special time, I think, in terms of standing up a new model, the ability for us to use technology and process optimization in a different way. So the goal will be to get back to a place that doesn't include incremental investments, but there may be some spillover. But our -- what we're envisioning right now is bulk of that spend in '26 and '27 and dissipation in 2028.

Okay. How are you thinking about how much of an issue is it a risk that clients decline to move to the new model? And do you think this puts at risk your competitive position vis-a-vis others for some people that choose not to may want to just consider a traditional model?

So we see this more as an opportunity than a risk and a competitive advantage for us of understanding where the puck is going in terms of the pharmacy benefit space, the unpredictability around rebates whether it's the Inflation Reduction Act or it's the most favored nation, like there are a lot of things changing right now in the drug pricing landscape, which is causing some challenges from a client perspective in terms of rebate predictability.

This new model takes that and makes what clients are going to be paying much more predictable for them. It also simplifies it. So that's an opportunity of removing the complexity out of the pharmacy benefit space, how our pricing works, delinking pricing from the cost of the drug. That type of opportunity is going to be very attractive to our clients to where I think if we're sitting here in 2 years and we hadn't built this model, you'd be asking me why didn't we see this coming and why weren't we more prepared to have something new like this.

So I see this as a real opportunity for us to have something very attractive for our clients that will be available to them over the next 2 years. And at the same time, for those clients that want to stay on an existing type of model and want to continue to have their rebates, we're going to continue to make that available to them as well. So I don't see this again as a risk. I see this as a real opportunity for us, not only to continue to have strong retention of our current clients, but also from a new sales perspective of having something new and different that's out in the market and available to clients.

And keep in mind, the core components that we're going to continue to deliver to our clients, those pieces don't change in terms of adjudication of claims, the clinical services that we provide, formulary development, those pieces will continue to be there, and we're going to continue to invest in those as well for both models that we'll continue to support.

That's good. Okay. When you think about the administrative fee aspect of this or the PMPM fees associated with it, should we think that those fees have a risk component to them? Or are they largely just set fees only model?

Yes. So you can think about the PMPM fee. Let's think about fees in 2 categories. The PMPM fee is one category, and then there'll be fees for other services. So let me first talk about the first category. So the PMPM fee will not be a risk fee. That will be the fee that we charge clients for the services we provide. So drug price negotiation, the clinical and safety services, the administration adjudication of the plan. So those fees will not be risk-based, and they'll be based on -- and negotiated with the client and based on volume. The second category of fee will be around innovative programs like Adam mentioned earlier, Safeguard Rx, we have Enreach.

Those programs allow us to take risk positions or risk against our fees. And we're very excited about the prospect of expansion of those types of programs and the opportunity that, that provides us. But in short answer to your question, PMPM fee is not at risk. We will have a risk component to the fee structure, but that will be in the context of innovative products that bring clients to us and enhance the services that they have and also enhance affordability and client experience or patient experience, I should say.

Okay. There's certainly been some focus on how this model impacts the discussion around rebate guarantees. Some of your peers have had issues around specific categories of drugs with rebate guarantees. How much has that been historically part of Evernorth's approach to the market? And does this have an impact as you make this model, how might that evolve?

A.J., our ability to continue to meet our clients' contractual obligations on rebate guarantees has been manageable. We expect to continue to be manageable and to be able to meet those obligations. As I mentioned before, the unpredictability, though, of rebates and what's happening in the market today around changes like the Inflation Reduction Act is causing some friction in the market where we're working through those things with clients.

We do have the ability with the vast majority of our clients to be able to adjust those guarantees when different market factors may occur or government intervention may occur. So we've been able to work through those amicably with our clients to be able to make those adjustments. So we would expect this to continue to be manageable.

But it does speak to the challenges that exist in the market and why a new model makes sense and why moving to something that is rebate-free will make more sense, especially as you continue to see more of this disruption to continue to happen in the market where pricing is changing more today than we've ever seen it in terms of the different list price movement that we've been historically.

Interesting. Okay. You have these major contract renewals that you also announced. Are those -- do those envision those going to the new rebate model?

So the large client renewals whether that -- we've talked about Centene, Prime Therapeutics or the strong relationships that we've had with those clients and now we're -- the ongoing relationship that we're going to have. So we're thrilled to be able to extend those relationships for -- through at least the end of the decade. Those are all unique contracts because they are unique clients to us, and they're already in very transparent models, fee-based per claim type of models today. We will certainly offer to them the option if they would want to move to a rebate-free model.

So they'll have that available to them. But being nontraditional clients already, they already have fully transparent models that we work very closely with them on. And we're proud of the work that we've been able to do to service them, not only through today, but also for quite a few years to come. Right.

Right. And so there has been certainly some questions about why the need to do the proactive extension on these major contracts, I think Centene, Prime, and it sounds like DoD may have been early as well. Any -- I think all these contracts had some time to run. Just give us some perspective on why it made sense to do that.

Sure. Yes. So maybe for context, so the 3 large clients, you hit them all, DoD, Centene, Prime, altogether $90 billion worth of revenues associated with just those 3 clients and substantial volumes. Some of the clients were up for regular renewal and others were accelerated discussions. And so why we thought it was important to do that to accelerate. Obviously, we've got to go through the normal renewal process when it's appropriate. But for the acceleration, we really wanted to lock in through the end of the decade.

And why that's important is we've talked a lot about the new rebate-free model. Having sort of that $90 billion of revenues, those clients and the volumes that come along with those, give us stability heading into the end of the decade and allow us to transition to the new model without fear of disruption in that space or distraction. So we feel really great about the relationships, as Adam described, and very good about the fact that we've got them locked in and we can focus on executing on in the new model in the most powerful way possible.

Okay. Okay. Usually, when you have contracts of that size, you take a step down in margin upfront and then it's sort of over time, builds. It sounds like -- I wonder to what extent was there a degradation in profitability, and that's part of the adjustment and outlook that the company gave on the third quarter. And then it sounds like it's more of the margin is going to be steady from here as opposed to lift over time. Maybe just give some thoughts on those that.

Yes, sure. So correct, A.J. What we've said about next year is we expect some pressure due to these accelerations and renegotiations, and that's a bit more than half of the pressure. And so as we think about the future, those fees are -- those contracts are fee-based. We would -- there are some increases in fees over the period of time, but it's going to look different than it did in the past in terms of low earnings and jumps later on in the contracts. And I think Brian talked about this during the earnings call, sort of stable margins for the future for these 3 big clients.

Where we see the opportunity and Centene is a great example, is in terms of what we are doing for those clients and the opportunity to expand our relationships with them. So there's opportunity, in particular, in the specialty space with some of those clients to do more for them. And the better our relationships, the stronger the relationships, the better opportunities we have on the back end of that. So I'd see more of the opportunity coming from the expansion of the relationships on the margin side. I think you can think about margin holistically across Evernorth, right, our target is in the 3.5% to 4.5% range outside of the large clients getting back to those target margins over time.

I got to ask you about the GLP-1 announcements. I know a lot of people are still trying to figure that out. But what's your assessment of how that might affect? I know Novo and Lilly have made some comments. What impact do you foresee that having on the Evernorth business?

So the more recent announcement that they made with the administration, certainly, we're working -- we're engaged with both manufacturers. It's early as we're working through what those changes potentially could mean in working with Novo and Lilly. I think on its Phase 1, this looks like it's certainly a win for consumers and hopefully for our clients as well in lowering the cost of these medications, improving access to these medications. And as I mentioned earlier, our ability to continue to build out functionality, we'll be able to connect with any type of direct-to-consumer offering.

It also provides us with an ability to continue to negotiate to bring down those net costs overall. So although it's early, I would expect this, one, to be manageable; two, to be neutral to us as we continue to work through and to expand access in these drugs. And as they continue to expand the number of indications that are available and us to continue to work to make sure that we can provide affordable access to the patients that need these drugs most.

Okay. Maybe I'll pivot over to Cigna Healthcare for a second. I know we've been talking about the stop-loss business and the recontracting process. Any updates on how that's going, what you're seeing?

Sure. So not too different from what we said coming out of third quarter earnings. So just as a reminder, last year, we had an MCR in the low 90s in the business, a bit of a surprise in terms of how it evolved over 2024. So coming into this year, we've got a higher estimate than we did last year in terms of the overall MCR. We've been tracking against our expectations pretty much all year long. We are doing additional things this year. The standard things like looking at sort of paid ratios, everything is sort of in line with where we'd expect it to be.

The other things that we're doing outside of what we've done before is really in the analytics space. So we have developed analytics that is able to look at each individual in the book, where they are against their attachment point, and to assess what our best estimate of how things are going to progress through the rest of the year, which is only a couple of months now. All of that is progressing where we would expect it to be. Specific to the pricing question, pricing is going as we expected it to go, meaning we are pricing higher than we priced last year.

Our persistency is about where we'd expect it to be. 2/3 of the book reprices on January 1. So we're in that process right now, but it's going well. And we would still expect to recapture the portion of our margin recapture. And when we talked about it last year, we said over '26 in '27. We still see that as the path. So part of it will be '26 and the rest will be in '27.

Okay. Okay. At this point in the year, how would you characterize how the overall medical cost trend in commercial has developed. We've heard some refer to sort of an 8% to 10% range. Do you think -- when you think about '26, are you thinking about the cost trend, the underlying cost trend being stable? And I assume you would characterize your pricing for next year as being for margin stability. Any thoughts on any of that?

Yes, sure. I mean the cost trend continues to be high. We are pricing 2026 higher than we priced 2025. And so that is in process and happening. As I think about margins, if we look at the commercial book, excluding stop-loss, we expect -- we are in our target margins. We expect to be there next year. Stop loss, we're on the recovery. So we'll partially recover next year, but get closer to target margins. Then for the individual business, -- there's been disruptions this year. We're below target margins. We expect to make some improvement next year given where we've priced the book.

And on that, anything to say? I know individual is tiny, but we're in open enrollment now. Any early read on what you're seeing there in that business?

No early read. I think the timing is they have till December 15, and so no early read, but we do expect a contraction. We had at one point, 1 million lives in this space. Now it's less than 400,000. We expect that to be even less next year in the 20% to 30% range. No early read on what's happening. We kind of got to wait for the process to go through. But we did price for margin improvement. So we expect more...

We expect lower lives. I think you noted on the call and maybe even in the prepared remarks that cash flow is going to be back half weighted next year. But it sounded like the capital deployment from things like share repurchase would be more consistent over the year. When you think about -- is that true? And I think normally, we think about a 4% to 5% contribution from capital deployment. Is there any reason to think if the cash flow is back-end loaded that maybe it will be a little less next year. What's your thoughts on that?

Yes. If I think about the dynamics in terms of our cash flow trajectory, like you referenced being back half weighted. If you look at the past couple of years, it has been back half weighted. We had the benefit of the Medicare sale, which allowed us to do some repurchasing earlier in the year and in the back half of the previous year in anticipation. And so we've got that dynamic plus the other dynamic of -- we did the Shields transaction. Our leverage coming out of the third quarter was at 44.9% debt to cap.

We want to get to a roughly 40% range, not exactly, but approximately. And so we're working on delevering at the same time that we want to execute on other elements of the capital plan, one being repurchasing. So I would expect that we're going to be opportunistic and that there will be maybe some pressure to that additional 4% to 5% as it relates to repurchases only.

Okay. Okay. I think '27, the comment was made as you announced this model on the third quarter call that you'd see a return to closer to the long-term growth rate. We're trying to think about, is that because the comp will be easier because of what's happening in '26. It doesn't sound like there's incremental spending in '27 versus '26 for the new model. So you won't have a headwind on that. I think people are gravitating toward thinking about '27 as the low end of your 10% to 14% growth. Does that seem reasonable? I know there's a number of moving parts. Anything you'd like to elaborate on, on that?

To start with, that seems reasonable. We'd expect -- and we said this coming out of the third quarter call, it's reasonable to expect we get back into the long-term growth range of 10% to 14% in 2027. The headwinds that we have in 2026 around the contract renewals and extensions, that won't be a headwind going into '27. We'll continue to see the spend, but it won't be incremental, the spend on the transformation. It won't be incremental in '27 to '26. And so we'd expect to get back into our long-term growth algorithm.

Okay. With that, I think we're winding down. Any final wrap-up comments that you guys would like to make? I appreciate it. We've covered the waterfront here.

Yes. I would make one, which is typically in a lot of the conversations we've had with investors over the last few years, I get the question of what about government intervention? And we didn't talk about that today. And I haven't talked about that really with many investors since we've launched the new model. And I think the reason why is we've been heavily engaged with the President's administration, heavily engaged with members of Congress. And so as we've rolled out this new rebate-free model, it addresses many of the issues and challenges that exist of what we consider from a regulatory overhang.

We're addressing those things with the new model. And we're not doing it because of those things. We're doing it because it's right for the business. But I think it does speak to a new era for us as we introduce this new model and a new opportunity and why it's good for our clients. It's good for consumers, but it's also going to be good for us as well in addressing those challenges that exist in the market today.

And we did ask you, Adam, about the manufacturers, clients and your discussion with them. It sounds like you've had some discussions with policymakers, too, maybe what's their reaction to it? And can you give us a little flavor with what -- how those discussions have gone?

Overall, it's been positive. And I think you've seen the public tweets from Secretary Kennedy or from administrator Oz and others from the administration's members of Congress. Like what we're doing here is new, it's different. And it does meet many of the issues that they've been asking about and addresses those pieces to simplify the model, provide more predictability and transparency for clients and consumers alike.

Great. All right. Well, I really appreciate Cigna participating this year in our conference, and thanks, everybody. I hope you people have a great afternoon.

Thank you, A.J..

Ladies and gentlemen, thank you for standing by for The Cigna Group's Third Quarter 2025 results review. [Operator Instructions] As a reminder, ladies and gentlemen, this conference, including the Q&A session, is being recorded.

We'll begin by turning the conference over to Ralph Giacobbe. Please go ahead.

Great. Thanks. Good morning, everyone. 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, The Cigna Group's Chairman and Chief Executive Officer; Brian Evanko, President and Chief Operating Officer; and Ann Dennison, Chief Financial Officer.

In our remarks today, David, Brian and Ann will cover a number of topics, including our third quarter 2025 financial results and our financial outlook for 2025. Following their prepared remarks, David, Brian and Ann will be available for Q&A.

As noted in our earnings release, when describing our financial results, we use certain financial measures including adjusted income from operations and adjusted revenues, which are not determined in accordance with accounting principles generally accepted in the United States, otherwise known as GAAP. A reconciliation of these measures to the most 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 the signagroup.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 2025 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 to today's earnings release and in our most recent reports filed with the SEC.

Regarding our results, in the third quarter, we recorded a net after-tax special item benefit of $61 million or $0.23 per share. Additional details of the special items are included in our quarterly financial supplement. Additionally, please note that when we make prospective comments regarding financial performance, including our full year 2025 outlook, we will do so on a basis that includes the potential impact of future share repurchases and anticipated 2025 dividends.

With that, I'll turn the call over to David.

Thanks, Ralph. Good morning, everyone, and thank you for joining our call. In a highly disruptive market at The Cigna Group, we continue our track record of sustained growth in 2025, and I'm pleased to report that in the third quarter, The Cigna Group delivered strong results and continue -- in a continued dynamic environment.

Today, I'll briefly walk through how we will sustain our growth by accelerating innovation to meet the needs of our customers, clients and partners. We're also introducing new solutions to create meaningful value and impact, including our announcement earlier this week of a new rebate free model for pharmacy benefits. Then Brian will provide an update on our performance on our growth platforms as well as provide some perspective on 2026. Then Ann will share some more details on our financial results for the quarter. Then we'll open up for your questions.

Now let's get started. Third quarter, we delivered revenue of $69.7 billion and adjusted earnings of $7.83 per share, all while continuing to strategically invest in our business to drive growth and innovation. We've also taken further strategic actions to expand our addressable markets and position the company for future growth. One example is our recent investment in Shields Health Solutions completed earlier in September. Brian will share more details on this shortly.

Our performance this quarter also underscores that we continue to deliver for those we serve, consistently navigating through dynamic and challenging environments. For example, this year alone, we publicly committed in February to a series of actions to further ease access to care in a coordinated way for patients and the physicians. Then we step forward to partner with HHS Secretary Kennedy and CMS Administrator Oz, along with others, on a broad set of initiatives that will create a more seamless access to care environment and care continuity for Americans, for example, when they switch health plans.

Additionally, earlier this month, Evernorth fertility pharmacies work with the Trump administration and EMD Serono to make fertility treatments more accessible for Americans struggling to start or expand the families. And just this week, we announced our transformative new rebate-free delinked model. Our pharmacy benefit services here are designed to improve health care affordability and the experience for tens of millions of Americans.

Our durable business model is designed to evolve, flex and thrive through a variety of changes, whether anomic, regulatory, legislative or evolving technologies. Today, the powerful forces of change across health care are accelerating and converging around long-standing challenges, particularly balancing access and affordability for consumers and patients. Drug pricing continues to create a significant affordability challenge and has become an even more intense part of the public dialogue in 2025.

One area where we've helped address affordability relates to generic drugs with Americas today enjoying the lowest prices in the world for these medications. In fact, generic drugs now account for 90% of all prescriptions. And on average, they are 1/3 cheaper than in the United States than in other countries. And pharmacy benefit managers and the industry as a whole have played a key role in contributing to these lower costs by leveraging a competitive environment for clinically equivalent drugs.

Now on the other hand, prices for brand-name medications continued to skyrocket. With those drugs that do not have a generic equivalent costing 4x as much as the same drug in European markets. And in 2025, it's estimated that the median price set by drug companies for new FDA-approved drugs is projected to be approximately $390,000 per treatment course. As a result of these marketplace dynamics, even though brand name drug medications comprise only 10% of overall pharmaceutical volumes in the United States, they account for 80% of the spend.

In recent weeks, President Trump announced a series of initiatives aimed at lowering the cost of brand name medications, bringing the U.S. prices in line with those paid in other developed countries. We are aligned with these efforts and seek to expand access for all our clients, from employers to health plans and governmental plans so that even more Americans can benefit from fair pricing on the prescriptions.

Additionally, similar to our work to reduce pricing in generics, we continue to advocate for necessary changes to accelerate and broaden access to biosimilars, which boosts competition and lowers prices further. For example, the list price of HUMIRA is approximately $7,000 a month. That approaches $85,000 a year for this single medication. Thanks to our innovative offering, we provide customers with HUMIRA at a biosimilar level at no cost to the individual consumer.

From a consumer point of view, that's real value and that's innovation that matters. Even with these efforts, we continue to advance change for the benefit of our customers, clients and patients. We've deliberately shaped our well-balanced portfolio of businesses across 2 growth platforms at The Cigna Group, Cigna Healthcare and Evernorth Health Services. As a reminder, Cigna Healthcare is approximately 40% of our enterprise earnings. And in Evernorth, Specialty & Care and pharmacy benefit services are approximately 30% each.

So 70% of our portfolio, Cigna Healthcare and Specialty and Care Services remain well positioned for growth in 2026 and beyond. And to future-proof our company within our pharmacy benefit services, we continue to take significant actions. First, we proactively secured a number of long-term large client renewals and extensions including the U.S. Department of Defense, Prime Therapeutics and Centene. We're pleased to be able to serve them and their customers and patients now and through the end of the decade and beyond.

Second, we've stepped forward with our new simple and transparent model for pharmacy benefit services, which will replace the complex post-purchase rebate process with a simple upfront discount, which will enable customers and patients to automatically pay the lowest price at the counter, whether through their benefit or on a cash pay basis and apply the payments or the deductible. And importantly, continue to provide approximately 18,000 clinical safety checks as well as care coordination programs, which are essential for Americans who are taking multiple prescription medications that may have dangerous interactions.

To make the benefits of this model even more evident, consider this, for Americans and health plans where they pay the full cost of medications, including, for example, high deductible plans, our new model will reduce the cost for a brand-name drug prescription on average 30%. This will be real savings for the consumers, and they'll see it right at the counter. Cigna Healthcare will adopt this model 100% for fully insured lives beginning in 2027, and it will become our standard offering broadly for The Cigna group to the marketplace starting in January 2028 and we expect to transition at least 50% of our book of business into this new model by the end of 2028.

Consistent with this direction, we are also creating a more sustainable economic model for independent pharmacists we contract with. We understand the critical role these clinicians play in health care, particularly in rural at-risk communities and commit to continuing to support them with fair competitive pricing reimbursements for dispensing medications as well as clinical services they provide for customers and patients.

Further, the combination of market forces and our capabilities position us to proactively drive these long-term strategic renewals, extensions and program transformations to positively impact the marketplace for years to come.

Now over the next 2 years, we will invest to support these renewals extensions and innovations. These investments will support recontracting efforts cross many clients and supply chain partners, technology improvements, process reengineering as well as building a further enhancing data and analytical capabilities. Additionally, given the significant financial and affordability pressures for partners operating heavily in government programs, we have proactively improved the economic terms of the contracts for the benefit of these long-term strategic clients.

As a result of these factors, we expect margin pressure within our Pharmacy Benefit Services segment over the next 2 years. To be clear, we expect a sustained and durable growth trajectory over the long term for the business. I also want to be clear, even with these significant investments, we expect to grow EPS in 2026. Brian will discuss this further in a few minutes when he addresses our tailwinds and headwinds. All these actions demonstrate the commitment and resolve from The Cigna Group to build a better future and sustain our growth and impact.

Now to wrap up, against the backdrop of a dynamic and challenging environment, our third quarter results and our reaffirmed EPS outlook of at least $29.60 underscores the strength of our diverse portfolio of businesses and sustained disciplined execution and focus.

With that, I'll turn the call over to Brian.

Thank you, David. Good morning, everyone. I'll start by emphasizing our continued performance and delivery through a dynamic operating environment. Our strong fundamentals, disciplined focus on execution and innovative mindset position us to continue demonstrating leadership for the benefit of those we serve and to build a more sustainable model for health care. Our continued success is rooted in the reasons our clients choose to partner with us, our breadth of capabilities, our clinical excellence and our benefit plan administration. Taken together, our expertise in these areas enables us to provide access to quality health services and prescription drugs at lower unit costs than clients could achieve on their own, helping them meet their affordability goals, programs and services that deliver personalized care and prioritize patient safety and efficient and effective management of their complex benefit plans.

Today, I'm going to cover 2 things. First, I will go through our third quarter performance across our businesses, and then I'll touch briefly on the tailwinds and headwinds we see for 2026.

Let's begin with our performance in Evernorth and Cigna Healthcare. Evernorth Health Services delivered earnings in line with expectations in the third quarter. Our Specialty and Care Services businesses had another strong quarter where we delivered 11% adjusted earnings growth, reflecting our ability to deliver meaningful value to those we serve. Already this year, our specialty pharmacies have delivered approximately 7 million prescriptions, growing at a double-digit rate from last year. And we are continuing to see a strong shift to biosimilars for HUMIRA and STELARA, saving patients millions of dollars in out-of-pocket costs. This quarter, we also completed a strategic investment in Shields Health Solutions, further expanding our existing specialty capabilities to serve health systems, hospitals and other providers. We're excited about the multiple future opportunities in the over $400 billion specialty market.

With our investment shields, we are enhancing our ability to serve the provider administered portion of the specialty market, which today represents approximately 40% of the specialty space. This addressable market has strong secular growth and our investment in Shields will enable us to accelerate our strategy in the hospital and health systems segment that Shield serves. We're also pleased to be part of an effort by the Trump administration to make fertility treatments more affordable for Americans.

As David noted, earlier this month, we announced that in conjunction with the launch of TrumpRx, we will expand our successful partnership with EMD Serono to deliver fertility treatments from our Evernorth fertility pharmacies in 2026, providing lower cost and differentiated clinical capabilities for the benefit of patients. All in, we see a number of growth opportunities in our Specialty and Care Services business. With our combined suite of capabilities across Accredo, CuraScript SD and CarepathRx, we have opportunities to enhance and expand the ways we support specialty for all stakeholders.

Now I'll turn to our second major platform within Evernorth, our Pharmacy Benefit Services business. We are proactively transforming our pharmacy benefits model to meet the demands of the market and improve affordability and experiences for our customers and patients. We're also seeing strong client retention and demand for our services. And as the 2026 selling season comes to a close, we expect approximately 97% retention in our Pharmacy Benefit Services business.

During 2025, we proactively executed renewals and extensions with our largest clients, including Prime Therapeutics and Centene, building on our previous extension with the Department of Defense. We recognize there are significant financial and affordability pressures for partners operating heavily in the government programs market. We have proactively improved the economic terms of the contracts for the benefit of these long-term strategic clients. We're pleased to have these partnerships secured through the end of the decade, given their attractive long-term economics. Separately, we're also continuing to see positive impact from our suite of GLP-1 offerings, EncircleRx, EnReachRx and the new and Guide pharmacy. These offerings are anchored around affordability, access, clinical support and patient safety. This includes access to FDA-approved medicines, prioritizing adherence, hopper dosing and a focus on diet and exercise to ensure durable lasting results for our patients.

Across Evernorth, we had a solid quarter as we continue to grow our specialty and care capabilities and invest in our Pharmacy Benefit Services model, strengthening our leadership position and delivering solutions for the future. In Cigna Healthcare, we delivered financial results that were in line with expectations, underscoring the resilience of our portfolio and business mix, even in an environment of persistently elevated medical costs. This performance reflects our ability to navigate dynamic market conditions while delivering on our commitments to those we serve, along with targeted customer growth, including an 8% increase in our under 500 Select segment, and continued strong performance in international health.

As it relates to the medical care ratio, we were pleased with solid performance in the quarter from our U.S. employer business, including stop loss, which performed in line with expectations. Our overall Cigna Healthcare segment-wide medical care ratio was 84.8% for the quarter, driven by an updated view of risk adjustment in our individual exchange business. Across all of our Cigna Healthcare customers and clients, bending the cost curve and delivering affordability is more critical than ever.

As I noted, our clinical expertise and support programs are key reasons why our clients choose to partner with us. We're investing in predictive capabilities that allow us to engage our customers at the right time to support their care needs more effectively. We also enable clients and customers to access high-performing providers through value-based reimbursement models that align incentives and drive better outcomes. In Cigna Healthcare, we're proud to have delivered another solid quarter, fueled by the strength and diversity of our portfolio and our operational focus.

Next, I'll share a view of some of the tailwinds and headwinds we anticipate for 2026. Notable tailwinds include continued strong growth of our Specialty and Care businesses, including our investment in in partnership with Shields Health Solutions. In Cigna Healthcare, consistent with prior commentary, we took corrective action to reprice the stop loss business beginning early this year and expect to benefit from margin expansion within that business in 2026.

Turning to headwinds. In Evernorth, the aforementioned renewals and extensions will generate a modified margin profile going forward for these large clients. And our new rebate-free pharmacy benefits model will incur short-term investment and transition costs, including for technology and operational reconfiguration as we accelerate transformative change. And within Cigna Healthcare, the absence of nonrecurring benefits in 2025, specifically related to our divested Medicare businesses as well as our individual exchange business.

Taking these factors altogether, overall, we expect EPS growth in 2026. In Evernorth, we expect operating income to be slightly down in 2026. Our Specialty and Care Services business will grow income towards the higher end of its long-term growth target, offset by a decline in Pharmacy Benefit Services. In Cigna Healthcare, we expect operating income to grow towards the higher end of its long-term growth target.

As I wrap up, I'd like to reiterate some bright spots for the quarter. We continue to deliver strong business performance and operational execution even in a dynamic environment. Evernorth continues to see strong growth in specialty, and we delivered 11% adjusted earnings growth within Specialty and Care services, reflecting the strength of our capabilities and clinical expertise. We're proactively bringing market-leading innovations such as our new rebate-free de-linked fee-based pharmacy benefits model that will deliver more value to customers and clients and simplify our economic model.

We've also extended our relationships with our 3 largest Evernorth clients through the end of the decade, providing further multiyear predictability. And Cigna Healthcare is successfully navigating a dynamic environment and delivering on our financial commitments, with notable strong medical customer growth in our select segment. Overall, we remain confident in the growth opportunities ahead, supported by strong fundamentals and secular tailwinds that position us to deliver even greater value for our customers clients and shareholders.

Now I'll turn it over to Ann.

Thank you, Brian, and good morning, everyone. Today, I will review Cigna's third quarter 2025 results and discuss our outlook for the full year, which we reaffirmed this morning. As David and Brian mentioned, our strong third quarter results demonstrate our ability to execute and deliver on our financial commitments in a dynamic environment.

Key consolidated financial highlights for the third quarter include: revenues of $69.7 billion and adjusted earnings per share of $7.83. Our performance through the first 3 quarters gives us the confidence to deliver on our full year 2025 adjusted earnings per share outlook of at least $29.60.

Now turning to our segment results. I will start with Evernorth. Third quarter 2025 revenues grew to $60.4 billion, while pretax adjusted earnings grew to $1.9 billion, in line with expectations. Specialty and Care Services continues to deliver strong growth with revenues up 10% to $26.3 billion and pretax adjusted earnings up 11% to $928 million, consistent with expectations. This performance reflects strong specialty volume growth and increased biosimilar adoption.

We continue to see drugs used to treat inflammatory conditions, advanced pulmonary conditions, rare diseases and infertility as some of the drug classes that have seen the largest increases in utilization. As these trends continue, we remain well positioned to build on this momentum leveraging our expertise in specialty to drive affordability and strong clinical outcomes for our clients and patients.

In our Pharmacy Benefit Services business, revenues were $34.1 billion and pretax adjusted earnings were $1 billion, in line with expectations. Pharmacy Benefit Services results in the third quarter reflect the rate and pace of investments including initiatives to improve the patient experience and accelerated biosimilar adoption, consistent with our prior commentary. Taken together, we are pleased with the performance of Evernorth in the third quarter.

Turning to Cigna Healthcare. Third quarter 2025 revenues were $10.9 billion, and pretax adjusted earnings were $1 billion. Cigna Healthcare pretax adjusted earnings were in line with expectations. Overall, results in our U.S. employer business, including stop loss and our international business were consistent with expectations, while our individual business had an impact on our medical care ratio of 84.8%, reflecting an updated view of risk adjustment revenue. The higher medical care ratio in the quarter was offset by operating cost efficiencies.

Now turning to our outlook for full year 2025. Given the strength of our results through the first 3 quarters, we have the confidence to reaffirm our full year 2025 expectation for consolidated adjusted earnings per share of at least $29.60. Our full year 2025 outlook for pretax adjusted earnings for each of our reporting segments remains unchanged. In Cigna Healthcare, we now expect our full year medical care ratio to be at the high end of our full year guidance range of 83.2% to 84.2%. This is driven by a higher expected MCR in our individual business.

Turning to our 2025 capital management position. Third quarter operating cash flow was $3.4 billion, and we continue to expect strong cash flow from operations in the fourth quarter, similar to the pattern we observed last year. Our debt-to-capitalization ratio was 44.9% as of September 30, 2025. The increase primarily reflects the impact of debt issuance associated with our investment in Shields Health Solutions. We continue to target a long-term debt to capitalization ratio of approximately 40%, and we expect to progress towards this target in the fourth quarter.

Looking ahead to 2026, we expect another year of strong growth in Cigna Healthcare and Specialty & Care services, both at the higher end of our respective long-term growth target. And as David and Brian mentioned, we are proud to lead the industry with the proactive transformation of our new rebate-free pharmacy benefit model, which positions us for durable and sustainable long-term growth.

Due to the deliberate investments we anticipate making to implement this new model and the renewals and extensions of our largest clients, we expect adjusted operating income and pharmacy benefit services to decline in 2026.

Regarding our capital management position, we expect cash flow from operations in 2026 to be back half weighted, consistent with the 2025 pattern. Taken together, we expect EPS to grow in 2026. We look forward to providing further details on our 2026 outlook on our fourth quarter earnings call.

And with that, we'll turn it over to the operator for the Q&A portion of the call.

[Operator Instructions] Our first question comes from Lisa Gill with JPMorgan.

Obviously, a lot to unpack on the pharmacy side of the business. So first, I just want to make sure I understand a few things. One, we've heard from a competitor around rebate guarantees. From my memory, I don't recall Express Scripts ever having specific guarantees around rebates. So I want to clarify that, that's the case.

And then secondly, when we think about the renewal pricing going into next year, the shift over to the new rebate free model, I really want to understand the economics. Is it that as we move into next year, there is an incremental element to the renewal pricing? And then longer term, how do we think about those economics? And then when we put this all together, I think your long-term growth rate for Evernorth was 5% to 8% EBIT growth. Are you saying we're going to take a step back from that in '26, but the plan is to get there in this new model longer term? I know that's a lot, but I'm just trying to unpack all this.

Lisa, it's David. It is a lot. And clearly, there's a lot going on in the space. Let me come to a couple of headlines for you first and foremost. The new model that we just walked through is a model that we're extremely excited about. I'm personally proud of our team's ability to step back and architect the new model of the future that is fee-based, de-linked, transparent and has the mechanism to have the lowest available price for the consumer at the calendar on each transaction. And it's highly aligned with the regulatory priorities of the day. So that's frame one. .

To the core of your question, there's a few pieces in there. Our long-term algorithm for the Evernorth portfolio stays intact, number one. Two, for 2026, Evernorth will not be on that long-term growth algorithm. Specialty and care will be, and it will be at the high end of its growth algorithm. The segment as a whole, Evernorth as a whole will not be specifically focus on the PBS segment of our portfolio for the 2 reasons we talked about, significant investments in building these new sets of capabilities and the proactive actions we've taken around renewals and strategic extension of contracts, acknowledging the significant challenges of those that are serving the government-sponsored marketplace. We believe that the combination of those 2 actions materially future-proof that business for many years to come and are highly responsive to where the market needs to go.

To the last part of your question, and then I'll ask Brian to add any go-to-market comments specifically around value proposition to some of our stakeholders. The initial part of your question was around guarantees. Yes. There are instances where different dimensions of offering sub guarantees. We've not spent time with you all talking about guarantee volatility because, by and large, the aggregate relationships we have with our clients over many years, and the value we've delivered for our clients has performed in a dynamic and volatile environment. So -- but it's never been a headline that we've needed to bring to you on a regular basis. Importantly, ending where I started, the new model that we're building takes all that out of the equation. Rebates no longer exist. Reimbursements are no longer linked. They are transparent fee based, and they are highly aligned to the consumer low cost at the counter, which is why we're so passionate about it. Brian, maybe ask you to just highlight a few more of the benefits for our stakeholders on the new model.

Yes. Sure, David. Lisa, maybe just -- before I get to that, I'll touch on your question about how to model the medium and longer term, because I think it's important as you step back and reflect on what David just went through. So far in 2025, our Pharmacy Benefit Services business is tracking to expectations even in a challenging environment. So we're not seeing variability from expectations due to rebate guarantees or those sorts of drivers importantly. And for 2026, we do expect margin compression within our Pharmacy Benefit Services business driven by the 2 headwinds that we outlined earlier, specifically headwind one being the large client renewals and extensions that we secured through the end of the decade and headwind two being the transitional investment spend associated with this transformative new rebate free model, and that will result in meaningful cost across 2026 and 2027.

So when you think about modeling this business in the future, I would encourage you to think of it in 3 categories. Category 1 is represented by the 3 large clients that we referenced earlier. This represents roughly $90 billion of annual revenue and the 2026 margin profile should run rate through the end of the decade. We're thrilled to have these clients through the end of the decade.

Category 2 is the transitional and investment spend associated with our new rebate free model. This will result in margin pressure across 2026 and 2027, but it will largely dissipate thereafter. Category 3 is the fundamental earnings profile on the balance of the pharmacy benefit services book. You should think of this as not meaningfully changing from today in terms of client level earnings contributions, meaning that we would expect comparable earnings contributions from our rebate free model as we have today in our existing solutions. So you put that all together, all these actions strengthen the long-term durability of our Pharmacy Benefit Services business.

David asked me to touch briefly on what's in it for some of the stakeholders in terms of our new remodel. So let me just do a very brief run through some of the key stakeholders. So for patients, this model will insulate them from the high list prices set by drug manufacturers, even if they're a high deductible health plan. Our price assure technology will ensure that they always pay the lowest possible out-of-pocket price. Even in those rare instances where an alternative cash pay option is less expensive than our negotiated price. And if the patient does pay out a bucket, we will ensure that it applies to their deductible.

Our breakthrough new model also supports independent pharmacists by reimbursing them based upon their drug procurement cost plus a dynamic dispensing fee that varies based upon the clinical intensity of the prescriptions they're filling. Critical access rural pharmacies will receive a higher dispensing fee and acknowledgment of the crucial role these pharmacies play in our communities. And for our clients, I'll just use an employer to illustrate this quickly. It's a simple fee-based, de-linked payment structure that covers all administration and clinical programs. This offers the employer more budget certainty versus today's model, which is a post-utilization reimbursement approach. It also should result in greater employee satisfaction with their benefits. Today, often, their sticker shock when a patient is faced with the out-of-pocket cost for expensive brand drugs. This is a solution to that problem for employers. And we would expect stronger adherence to treatment protocols, resulting in improved employee productivity and presenteeism over time.

And from a shareholder perspective, we expect that this model will simplify the analysis of our company and provide you with more visibility, transparency and predictability of our performance. So long question, long answer. Hopefully, that helps.

Our next question comes from Justin Lake with Wolfe Research.

I'll stay on the PBM here. First, just any color you can share with us in terms of the magnitude of that 2026 decline, is it low single digits, mid-single digits, not a [ $0.01 ] down on the number, but just maybe a range you could help us with, so we could think about the magnitude of the pharmacy benefit pressure there next year?

And then you -- so it sounds like you're saying the renewals will play themselves out next year, and it's really that transition and investment spend that will be the pressure in 2027. So maybe you could give us some color on how much of that -- how big that investment spend bucket is maybe relative to the overall pressure and how much of that we should see in '27, just so we can understand how much of a -- do we get back to typical earnings in '27 growth minus whatever this investment spend is. Is that the right framework? And maybe give us some numbers on that.

Justin, it's Brian. So in terms of the second part of your question, your framework is right in terms of the large client extensions and proactive renewals, that will become a new run rate starting in '26 through the end of the decade plus. And the investment spending is the component that will continue into '27. So you've got the right frame of reference there.

as it relates to sizing the impact on the pharmacy benefit services operating segment for '26, just maybe I'll walk through a few of the components within Evernorth to help give you some color here. I just -- we're not giving explicit guidance today. This is meant to be more of a directional outline to help you understand what we see for '26.

If we start with our 2025 Evernorth income guidance of at least $7.2 billion, you can think of this as round numbers split approximately equally between Specialty and Care Services and Pharmacy Benefit Services. So that would be about $3.6 billion of income in each. And as I noted earlier, we expect the Specialty and Care Services business to grow towards the higher end of its long-term income growth algorithm, inclusive of the contribution from our investment in Shields. And we expect the aggregate 2026 Evernorth segment income to decline slightly from the 2025 level. So the delta between those 2 items represents the expected decline in Pharmacy Benefit Services in 2026.

Now the expected decline in Pharmacy Benefit Services income is attributable to the 2 headwinds that I made reference to earlier, one being the proactive extensions and renewals of our 3 largest clients, including both Prime Therapeutics and Centene during 2025. All of that results in a new margin profile on these clients going forward. You can think of that as that headwind being more than half of the overall Pharmacy Benefit Services decline in income that we expect for '26.

And then the second headwind for the 2026 Pharmacy Benefit Services income is the investment in transitional costs associated with our transformative new rebate free model. So this is less than half of the 2026 headwind for the PBS business. And again, while these are 2026 headwinds, both of them serve to extend the long-term value and the durability of our Pharmacy Benefit Services platform for the future. So hopefully, that helps with some of the components.

Our next question comes from A.J. Rice with UBS.

Just to maybe keep on trying to drill down that point. If you're looking at the Pharmacy Services business sort of at the higher end, the Healthcare business at the higher end of long-term targets. And then the PBM pretty much offsetting the growth in Pharmacy Services to the point where Evernorth is slightly negative, a couple of percentage points. I'm getting back of the envelope that, that probably generates EPS growth of roughly mid-single digits, 5% to 6%. I would just so people get off this call understanding in some framework, what you're describing. Is that generally in the ballpark? And are you making any assumptions about capital deployment, share repurchase, et cetera? And how they may contribute to growth in the next 2 years in this model?

And then I'm finally going to just ask a fundamental question on the new program. A lot of employers have had the opportunity to do pass-through rebates and so forth. You're going a step further in eliminating rebates. But a lot of employers push back and say, "Hey, they like that pool of rebates", have you got any early indications of how likely they are to want to adopt this model as you go out with it?

It's David. Two different questions. Let me give you some color on the first. First as you walk through the big box cars, I would ask you to think about it in terms of the earnings profile, and my comments will separate the EPS profile here in a moment. You have the big box cars CHC, 40% of the company on algorithm toward the higher end of the range, specialty and care on algorithm toward the higher end of the range, offset by the PBS downturn in 2026 driven by the 2 items that we drove ourselves relative to the strategic positioning of the franchise on a go-forward basis. We're not guiding to EPS for 2026. I appreciate the desire relative to that.

So we gave you the components of how to think about the earnings. The last piece I would encourage you to think about enhance prepared comments, sheet profile, our cash flow profile for 2025 is largely being back half weighted. The capital profile for 2026 will follow a similar pattern to be back-end loaded. So you may want to think about that in the context of how you're considering your own buildup and projections. Additionally, we've noted that we will balance share repurchase and deleveraging priorities over the near term. So I just will give you those components.

So the last part of your question, which is a very important part of the question, in terms of framing -- in terms of go-to-market. Yes, pass-through has been available for a long period of time. By the way, as have point-of-service rebates in the marketplace and we offer both. This goes beyond it. And just to reiterate your points, no rebates, delinked economics and importantly, a capability that validates for the consumer, lowest available price at the counter regardless of the mechanism that generates that and 95% of the situation, it's the benefits program that yields it, but in low single-digit percentage, which is meaningful given the number of scripts in America, it could be an alternative mechanism, we have the ability to facilitate it.

We indicated this will be our standard offering as we look to the future. We will carry Cigna Healthcare's guaranteed cost portfolio crossed to it on January 1, 2027. It will be our standard offering out of Evernorth for the 2028 cycle, and employers, let's say, for example, as you infer, maybe a collective bargaining union employer or state employer, if they still want a different program or they want to transition over a multiyear period of time, we have the broad suite of capabilities. We have a broad suite of capabilities.

And lastly and importantly, we have the consultative approach to work 1 employer, 1 buyer at a time to come up with the transitional strategies that work best for them based on how they design the program, ending with, we believe this is the future of where the market is going. We're proud to lead it. And we need to have the capabilities to be able to serve the consumer, the employer and the independent pharmacists with the model.

Our next question comes from Andrew Mok with Barclays.

I wanted to follow up on the Evernorth comments. My understanding was that some of those large contracts were only modestly profitable, and now you're talking about lower profitability on those contracts. So is it fair to think that some of them might be operating at a loss near term? And how should we think about the progression of profitability over a multiyear period?

Andrew, I'll start. We don't comment on individual contract profitability, number one. Two, I think if you take the bigger picture, typically in business of all shapes and sizes, very large relationships have lower earnings profiles than a portfolio as a whole. So a directional comment going with you, I'd ask you to consider, we proactively extended. We proactively work to restructure, and we engaged in energized renewals for these contracts. Said otherwise, we're pleased to have these relationships, and we're proud to be able to support and service the DoD be a differentiated partner for Prime and be a strategic partner for Centene. So we proactively collaborate to generate this. I'm not answering your numbers. I'm coming back to lower margin profile, yes, on $90 billion, as you would expect. You should assume we would not have proactively engaged in these relationships if we didn't deem them be strategically important. And maybe Brian comment a little bit relative to the relationship and the evolve relationship we have with the parties as well.

Andrew, just a couple of comments I'd pile on to David's start there. One, we don't write business at a loss constantly, so you should not expect that these contracts are running at a loss on a sustained basis. But to David's point, they do run at a lower margin profile on balance compared to the overall portfolio.

It's also important to note that across the pharmacy benefit services client relationships that we have, many of them deepen over time. So sometimes that's our strong specialty capabilities or home delivery pharmacies or some of our care services capabilities such as our virtual care platform, MDLIVE. So oftentimes, the relationships deepen and expand over time. We're not banking on that happening with any of our 3 large clients here, but it is an opportunity for further value creation in the future.

Our next question comes from Charles Rhyee with TD Cowen.

Maybe, David, obviously, you're making this choice to strategically move the business model going forward. And I appreciate all the comments that you had here. You're kind of going it alone at the moment. You talked about sort of the examples with prior at earlier this year. Can you maybe give us a sense here on what the dialogue might be like in Washington between yourselves and other some of your peers, it does seem like the work that you're doing with administration IVF and some of the other things seems to suggest that the environment is better in terms of coming to some type of bigger resolution and trying to see -- do you see room to find more common ground either with regulators or the administration to maybe come to some more broader resolution that could perhaps lift this regulatory overhang that's kind of been on the industry for years.

Charles, thank you for the question. I guess I'll come at it through a few frames as you paint the picture. One, we've long as a company believe that sustained public-private partnership collaboration is critical in the United States. If you step back and look at the way in which programs are designed in the United States, having good alignment of public-private partnership is quite important in the interdependencies of the programs, be they employer, Medicaid, Medicare, exchange or otherwise, there are interdependencies between the way the programs function.

Point 2 is, if you paint the last year and you referenced some of the components, you can think about actions we've driven in a few categories. One, further extending public-private partnership. Example of that I cited in my prepared remarks and pleased to see the industry more broadly stepping forward with Secretary Kennedy, CMS Administrator Oz relative to changing and transforming [indiscernible] authorization work. and changing and transforming continuity of care between health plans for an individual that no action of their own results in a preapproved event in December. Their health plan changes over in January. They today have to go through a new event. We took that off the table. That's a good example.

Or as you referenced, the fertility outcome on an expedited basis, taking our capabilities, understanding the need statement and through public-private partnership evolving a capability with EMD Serono, ourselves, the administration going forward. That falls into public private partnership.

Bucket 2 is sustained relentless innovation. And you use the go it alone phraseology, I won't put it uniquely in the go to alone. If you just look back at the GLP-1 space over the recent past, we led the industry with our Encircle program that acknowledge and recognize the need to have broader programs wrapped around GLP-1s for employers around lifestyle management, behavior modification, titration of medication programs on an individual-by-individual basis. We're pleased to have over 10 million individuals benefiting from that program today or an expansion of a program that didn't have 1 drug had both leading drugs with a different program for employers, they can't be out of pocket up to $200. So those are examples of continued innovation like our Pathwell programs or otherwise.

And the third category are step function transformations. This is the step function transformation. We should be very blunt about it. It is a reframing of the marketplace to where the marketplace needs to go, whether you look at it through the consumers' lens, the consumer even on 5% of the pharmaceuticals in America, if there's $6 billion -- 6 billion prescriptions, if 5% or 3% of them have some dislocation at the counter, that's too many. That's too many for Americans.

And while benefit programs have been designed comprehensively and responsibly by employers, by health plans, by governmental agencies, there is increasing friction for the consumer. This takes that out of the equation. There is increasing complexity for the employer. As Brian referenced, this takes that out to the equation, and there is more support for the imminent pharmacist. All of that is to say that we're driving public-private partnership. We're driving innovation, and we're driving step function growth. And there is good collaborative engagement in Washington, relative to the direction, the importance and the need, and we will continue to lean into a nonpartisan fact base patent customer-centric engagement in Washington going forward. So this is an important moment for us, and I appreciate your question. Good progress through all fronts of the 3 categories I referenced. Thanks for your question.

Our next question comes from Scott Fidel with Goldman Sachs.

Well, I guess one of us should probably ask about Cigna Healthcare, so I'll do that, appreciate the framing that you gave around 2026 and the growth in Cigna Healthcare expected to be towards the higher end of the long-term algorithm. Can you walk us through maybe some of the key building blocks that are the inputs into that? And just thinking about some of the most impactful dynamics that have been driving sort of fundamentals there. One, stop loss. It sounds like that was in line with expectations in the quarter. How does that sort of feed into the expectations at next year? And then that the Exchange business as well. And just within the Exchange business, if you have any sort of framing around sort of the pricing and enrollment expectations that you're sort of building to get to that?

It's David. Good to hear for you. It sounds like you may have a little bit of a cold. So hopefully, you're doing okay. I'm going to ask Brian to provide some color relative to the comment you articulated because there are several pieces here in your question. One is building blocks that support the outlook for 2026, and there's a couple of important ones you called out. And as he talks, for example, through the stop loss component, maybe I'll invite Ann to talk a little bit about what we've seen on a year-to-date basis and the results, and Brian will talk a little bit about what we're seeing in terms of the go-to-market component and then I'll punctuate on the back end the individual or the exchange-based programs.

Before I hand it over to Brian in a nutshell, we're on track in 2026 for our growth outlook and algorithm. And by and large, our 2025 performance is in line with our expectations with the exception of, as called out in advance some of the pressure we saw in the individual exchange business. Brian, could I ask you to talk a little bit about the Cigna Healthcare tailwinds and headwinds for 2026?

Sure, David. Scott. So for Cigna Healthcare, which represents again about 40% of the company's earnings, we expect tailwind from the repricing of our stop loss business within the U.S. employer portfolio. Now this is partially offset by the absence of some nonrecurring benefits that we had in 2025, specifically the contributions from our divested Medicare business as well as some prior year true-ups in the individual exchange business. So when you net that all together, we expect that 2026 Cigna Healthcare income will grow toward the higher end of our long-term income growth algorithm.

As it relates to stop loss, we're tracking well as it relates to the 2-year margin recovery plan that we outlined in our fourth quarter call. So we've been able to execute against the higher rate actions that we required with typical levels of retention. So we're quite pleased with the performance of that year-to-date in 2026 will be a step forward toward the ultimate margin recovery that we expect to be completed by the end of 2027. And so far, the claims experience on that business has been running in line with expectations in 2025.

As it relates to the '25 performance, Ann, do you want to talk about what we're seeing in stop loss and individual exchange a bit?

Yes, sure. Thanks, Brian. So as Brian said, our stop loss business continues to track in line with expectations. So just as a reminder, we had assumed a higher MCR for this year compared to last year, which was in the low 90s. So a few things I'd note on what we're seeing sort of as we're sitting here now in the fourth quarter, our rate and execution -- rate execution, excuse me, and persistency, as Brian said, are tracking in line with expectations. I'd also point to the paid MCR, which measures claims as a percentage of premium collected. That is tracking where we would expect it to be at this point in the year.

In addition to those stats, we are analyzing how the results are tracking against expectations. We've developed enhanced analytics. In addition, this year that include those that leverage both claims and clinical data to predict individual claims experience, so using these analytics, we've constructed a range of stop loss outcomes based on where members currently sit against their pulling points and predictions of their future claims, those analytics reinforce our expectations for the full year. So taken together, we feel good about expectations for the stop loss book this year.

Our next question comes from Kevin Fischbeck with Bank of America.

I just want to make sure that I'm clear about what you guys are communicating around the investment spending component of the pressure on the PBM business. When you say that the investment spending will continue into 2027. Are you saying that it's going to be a similar year-over-year drag in '27 or that it's stable in '27 before margin recovery in '28 as you start to overcome those investments and recapture them?

Kevin, it's Brian. So it's more of the latter, if you were to think about the choices that you outlined there. You can think of the investment spending continuing from '26 into '27. So at this juncture, we don't anticipate that being a year-over-year headwind '27 over '26. Maybe let me elaborate a little bit on the nature of it, just to give you a little more texture here.

So as I noted earlier, this is one of the 2 headwinds that were impacting our Pharmacy Benefit Services business as we head into 2026 with the other being the large client renewals and extension. And the investment in transitional spending represents less than half of the Pharmacy Benefit Services headwind. Now importantly, as we've said multiple times here, this is a fundamental business model pivot much more than just simply a new product launch. So as a result of that, there's some substantial technology investments required, both some that are market facing as well as others that are more back office in nature.

So just keep in mind, our existing infrastructure really has been built around a pharmacy rebate oriented ecosystem. Secondly, we do have a series of recontracting work that needs to be completed in order to deliver the model. So think of this as manufacturer contracts, network pharmacy contracts as well as client contracts. So overall, these are fairly substantial changes that represent, again, one of the drivers of 2026 being a transitional year for our PBS business. But you should think of the spend levels as being broadly consistent between the 2 years. David, anything you...

Kevin, just maybe to give you a summary, I think we're going with your question. And I'm going to give you a directional comment as opposed to a financial comment. As you think about the building blocks of the capabilities, our CHC were on algorithm in '26, Specialty and Care on algorithm in '26, PBS of algorithm in '26. As you play that forward another year where you're going in terms of the moving points, Brian indicated the greater than 50% in the PBS part of our capabilities that is large client related will run rate going forward. So you have a different basis but new run rate going forward. And when you wrap it together, while there's investments that will carry into 2027, at this point, it would be reasonable to assume we would expect to be back on at the enterprise level on algorithm for 2027 with the strength of the franchise.

Our next question comes from Jason Cassorla with Guggenheim Securities.

Great. Maybe just for health care first, could you clarify, are you seeing health care AOI growth at the high end of your long-term target next year? Off of the AOI baseline that does not include some of the nonrecurring benefits like Medicare attribution, those true-ups? And then my real question for 2026. Are you expecting further membership growth there? Just any pockets or areas you want to highlight, you're looking for strong growth and any other puts and takes around membership to consider for next year would be helpful.

Jason, it's Brian. So on the first point, the again, directional commentary we're giving you today, we expect Cigna Healthcare income growth at the higher end of our long-term growth algorithm off of our full year guide. So no adjustments to that. So our guide is at least $4.135 billion. We expect to grow at the higher end of our income growth algorithm off of that. So just to clarify that.

As it relates to customer growth going forward within Cigna Healthcare, the portfolio is obviously quite diverse in terms of the different types of buyer groups within that. Our national accounts business, which is largely done for 2026 at this stage as it relates to January 1, we expect a flat to slightly declining customer outlook for '26, which is in line with our expectations over the long run given that our strategy is to maintain share in that part of the portfolio.

Our Select segment continues to grow, as I indicated in my earlier comments, also within the U.S. employer portfolio. And despite the higher rate increases that are in the market across all competitors. We're tracking for another good year of performance in the Select segment.

Our Individual exchange business, we expect to see a decline in membership next year, roughly commensurate with what the overall industry-wide enrollment is expected to look like. So those are the bigger building blocks as you think about the overall customer picture for 2026. So different rates of growth or decline business to business. But overall, we like the way we're positioned in Cigna Healthcare, again, confident in growing the income at the higher end of our long-term growth rate range.

Our last question comes from Erin Wright with MorganSo

Back in September, I think you mentioned that roughly in the range of 4% PBM margin would be durable or sustainable even with some of the potential permutations of outcomes from a PBM reform perspective, at least those that are out there today. And -- and is that still the right way to think about it, particularly also in light of the rebate free model transition over the -- obviously, this is over the longer term, excluding some of those nuances in 2026, '27. If you could comment on that longer-term margin profile?

Erin, it's Brian. So as it relates to the 4% margin benchmark we've provided in the past Pharmacy Benefit Services. We do believe that, that's a reasonable way to look at the business when you think about the long term. So as I made reference to an earlier question, we would expect the earnings contribution for our new rebate-free delinked model to be comparable to what the existing solutions are across the portfolio.

Now when you do the overall calculation at the portfolio level, depending on the mix of large clients, small clients, mid-market clients, the overall portfolio level margin may be higher or lower than that at any given point in time, but we would expect strong levels of contribution from our new rebate remodel comparable to what we see on a similar client level today with the existing solutions.

At this time, I'll turn the call back over to the speakers.

I just want to briefly wrap up our call today. First and foremost, thank you for joining, and thank you for your questions during our call. As I wrap up, I want to say how much I appreciate and how proud I am of our cobalt workers across the globe. It's their continued focus and dedication that support our ability to deliver on our commitments for those we serve, and generate the net benefits for our shareholders. And this is all in an environment that is dynamic as we both deliver on our existing promises and enable ourselves to design and deliver these new solutions and these transformative solutions for the benefit of our customers for years to come. We're proud of what we've achieved. We're jumping off a strong base in 2025 and 2026 will mark another strong year for the organization in our Cigna Healthcare portfolio and in our specialty care portfolio as we invest significantly in our PBS portfolio to future proof it for years to come. Thanks, again, and have a good day. .

Ladies and gentlemen, this concludes the Cigna Group's Third Quarter 2025 Results Review. Cigna Investor Relations will be available to respond to 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) 405-7290 or (203) 369-0603. There is no passcode required for this replay. Thank you for participating. We will now disconnect.