The Cigna Group (CI) Earnings Call Transcript & Summary

Please welcome Alexis Jones.

Good morning, everyone, and thank you for joining us today for Cigna's 2021 Investor Day. I'm Alexis Jones, Lead Principal for Investor Relations. And I'm excited to serve as your moderator for today's Investor Day. I hope that we'll be able to begin engaging with the investment community face-to-face later this year, but for today, I'm pleased to welcome you to our virtual event. And on behalf of the Cigna leadership team, I want to express our appreciation to you for taking time to be with us. Before getting started with our program, I have a few housekeeping items to address. First, I'd ask you in advance for your patience as our leadership team is participating in today's Investor Day from various locations here in the U.S. and overseas for precautionary health reasons related to COVID-19. As a result, we may experience some delays in the video transmission amongst our leaders speaking today. Second, when you joined the webcast, you confirmed you read the cautionary statement. As a quick reminder, please note that we will be making some forward-looking comments today regarding our outlook for 2021 and beyond. 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 our most recent filings with the SEC. I also want to remind you that Cigna uses certain non-GAAP financial measures when describing our financial results. Throughout today's presentations, when we refer to the term earnings, earnings per share or EPS, we mean adjusted income from operations in aggregate and on a diluted per share basis. Likewise, when we refer to revenue, we mean adjusted revenue. Definitions of these non-GAAP measures and reconciliations to the GAAP measure as well as definitions of other key financial and business terms are included in materials posted to the Investor Relations website. Additionally, I would also note a full set of our presentation slides will be posted to our Investor Relations website later this morning as we transition to the question-and-answer session of the agenda. So let's get to today's agenda. Today, you will hear some key themes from our passionate leaders, grounded in our mission to improve the health, well-being and peace of mind of those we serve and centered on our focus on driving growth with purpose. First, we will discuss how Cigna is well positioned for growth as our businesses and capabilities are aligned to the key macro forces fundamentally changing health care, are guided by our well-defined and durable growth framework and are building on a strong track record of delivering sustained growth. The team will then walk you through how Cigna's 3 growth platforms: Evernorth, our U.S. medical portfolio and international markets, are leveraging our growth framework. We will demonstrate how our ability to deliver differentiated value drives growth in our existing markets and existing products; how our relentless focus on driving innovation and developing strategic partnerships improves the affordability, predictability and simplicity of health care, driving further differentiation and opening up new markets; and how we have significant runway to expand our addressable markets we serve by entering new geographies, developing new solutions and serving new buyer groups both in the U.S. and globally. And we will pull this all together to share how our service-based, capital-light model has driven and will continue to drive attractive shareholder returns as our businesses generate significant operating cash flow, which provides us with both strategic and financial flexibility. Our leadership team is looking forward to the opportunity to discuss these important topics with you today. We will then provide you the opportunity to engage directly with our leadership team to answer your questions. So before I turn it over to David Cordani, our President and Chief Executive Officer; and the rest of the team, I'd like to run a quick video to kick us off to show how we are changing health care to deliver greater value for those we serve and deliver growth with purpose. [Presentation]

Thanks, Alexis. Good morning, everyone, and welcome to our 2021 Investor Day. I want to start by thanking you. We recognize your time is very valuable, and we appreciate you being here with us today and also for your ongoing interest in our company. Now when we met at our last Investor Day, which was in May of 2019, we outlined how we would leverage the power of Cigna's combination with Express Scripts to continue to fundamentally change health care and deliver sustained attractive growth by creating differentiated value for those we serve. Since then, we have delivered on and advanced our promise and led the way in what has proven to be a dynamic and challenging 2020. All of this is thanks to the effort of our 70,000-plus colleagues around the world who do whatever it takes to change people's life for the better. This commitment and this passion is what we call growth with purpose. It is our north star, and it guides what we do. For example, it guided our response to COVID-19, where we took early and decisive action to support our clients, our customers, our patients, our partners and our communities. It's also what compelled us to speak out against racism and to reaffirm our commitment to diversity, inclusion, equity and equality. And it's what requires us and continues to challenge us to ask what more we could do to be a positive force both inside our company and outside our company. Now as it relates to health care, our purpose guides us to make health care more affordable, predictable and simple. And while these may sound like ordinary words, within our company, they're guides and calls for action because we recognize that the current health care landscape is highly dynamic and challenged as for example, COVID-19 and the rollout of vaccines puts further pressure on an already overburdened health care system as costs around the globe continue to rise and our world's population ages and become sicker and as the health care system continues to be fragmented. At Cigna, we know this is not sustainable. However, we're not comfortable just to observe the problems. We challenge ourselves because we envision an environment that is affordable, that is predictable and that is more simplified. And we know we could deliver this because we have the right mix of talent, expertise, capabilities and a portfolio of businesses to take bold steps forward, to challenge the status quo and to advance meaningfully change by creating deliberate and disruptive action to existing business models, all with the objective to create more value for those we serve. Now to be clear, the actions we take are guided by our purpose and mission. And we seek to convert those to differentiated results because we have a clear view of the forces of change on the horizon for health care, we have well-positioned growth platforms, and we have a clear framework to grow and strengthen our enterprise. Let me spend a few minutes on each of these. First, we see 3 key forces that are fundamentally changing health care as we look to the future. The first is the acceleration of pharmacological innovation. These include items like specialty pharmaceuticals, gene therapies, oncology medications, further vaccines and the evolution of biosimilars, all which we see representing the future of health care. For example, the FDA has already approved 52 novel drugs in 1 year alone in 2020. Second, we see a greater link between and recognition of the importance of looking at mental and physical health together. For example, we know someone with a chronic condition is more likely to have a mental health or substance abuse-related issue. And that has become even more prominent during the pandemic. And third, we see rapidly changing access to care models. The emergence of virtual care is an important example of this. We have seen consistent growth in virtual care over the past decade, and it's rapidly accelerated further during the COVID pandemic. At Cigna, we see this trend continuing and accelerating further, moving well beyond urgent care to primary, coordinated chronic and behavioral care. This is not only because virtual care provides a better health care experience in many cases, but it also significantly lowers medical costs, thereby improving affordability. In fact, we see the power of virtual care fueling our ability to drive total costs below CPI and ultimately to 0 or less. You'll hear more about this and how we expect to utilize MDLive over the course of the rest of our meeting. Now stepping back, to grow and thrive, we have deliberately positioned Cigna to respond to and leverage these forces as we look forward. And today, our team will discuss more about our positioning relative to each of them. Now the engine we use for converting these growth opportunities into differentiated results, there are 3 growth platforms. First, Evernorth. This is our health service platform. It houses our pharmacy solutions, our care coordination and delivery capabilities, our benefit management solutions and our intelligence solutions. Second is our U.S. medical portfolio, which encompasses U.S. Commercial and U.S. Government businesses. And third, our international markets portfolio. Here, we have our health and peace of mind solutions, which we offer in 30 countries around the globe, and our comprehensive solutions for the globally mobile that we serve worldwide. Now across these 3 growth platforms, we relentlessly execute a well-defined and durable growth framework, and it has 3 building blocks. First, we strive every day to deliver differentiated value to our clients, customers and patients. This enables us to retain, expand and add new business. Then we add to that building block 2, which is looking to partner and also relentlessly innovate. This enables us to deliver more value for those we serve, but it also fuels our third priority, which is working to expand our addressable market. Here, we broaden our reach, whether it be through new geographies or new buyer groups because of new solutions we're offering. Now guided by this framework, we leverage our capabilities, and we deliver innovative, flexible solutions for those we serve. Those could be in the form of integrated solutions where we tightly integrate medical, behavioral and pharmacy capabilities. They could be through point solutions, you're familiar with those, that's a single product or service that address a unique need or gap, such as stand-alone specialty pharmacy or stand-alone dental solutions; or increasingly, over time, through more coordinated services. Here, we bring together multiple point solutions. They could originate from medical, pharmacy, behavioral, wellness or other services. They could be within our company solutions or through partnerships. And then we aggregate those to create the right level of value and affordability for our clients and customers. So when you put all this together, our purpose and our growth are inextricably linked. Our purpose fuels our growth, and our growth enables us to have a broader reach and impact, which ultimately translates to more lives to serve and change for the better and importantly, as we grow, more resources to invest, all of which further accelerates the meaningful shareholder value creation we deliver for you, our shareholders. That's why today, our company is stronger and more resilient than ever. And it's why our team couldn't be more excited about our future. Now today, you're going to have the opportunity to hear that excitement and feel it for yourself from several leaders that you know very well, and you'll meet some new faces from our deep bench of talent in our organization. They'll spend some time with you talking about our strategies and provide tangible examples and actions we are taking to make health care more affordable, more predictable and more simplified. You'll also hear detailed examples about our growth framework and how it's being converted. And you'll see how our capital-light model generates tremendous operating cash flow, creating significant strategic and financial flexibility, all with the objective of supporting attractive, sustainable shareholder returns. Now before we get into those topics, I'd like to spend some time addressing a few questions that we know are on your minds. Our aim is always to be transparent and responsive. And in that spirit, we know you have questions about our organic growth outlook, questions about risks that could potentially derail our outlook and questions about the impact of COVID-19 on our results today and in the near future. But first, there are a few headlines that we hope you take away from our time together today. First, we fully recognize that the environment is disrupted. And we know growth doesn't come easy; it has to be earned. Second, we have a clear track record of delivering differentiated value, innovating and partnering and smartly expanding our addressable market, all this to fuel sustained long-term growth even in the most highly disrupted environments. And our company has attractive, sustained growth opportunities in front of it across our 3 well-positioned growth platforms. And importantly, we have the strategic and capital flexibility to take advantage of those opportunities. Over the course of our program today, we'll provide more context, examples and detail. And then Brian Evanko will come and pull it all together with our outlook, including our capital deployment plans with more specificity and discussion of our refreshed M&A priorities. And of course, we've reserved time for Q&A. So let's jump into those questions. The 3 specific questions I will address are, number one, given Cigna's business mix, what's driving your continued confidence in your growth projections? Second, when you think about risks to your outlook, be they economic, legislative or political, why won't Cigna fall off of its very attractive growth trajectory? And third, what is your outlook for the impact of COVID-19, the dislocation of it that you called out on your business for 2021 and beyond? Let's jump into question one. Let me address why we are confident that we will deliver on our plans, more specifically, our growth outlook. Our growth is driven by our capital-light business model and our market-leading capabilities and our significantly ongoing expanding addressable market. Said otherwise, our growth is not dependent upon meaningful U.S. employment increases, PBM script growth or drug inflation alone. To reinforce the fact that our growth opportunity is much broader, let's start with some context, beginning with our results. From 2010 to 2017, before our combination with Express Scripts, commercial adjusted revenue grew by about 9% compounded while adjusted earnings grew by 13% over the same time period. In that environment, our medical customer base grew by 3% on average over that time horizon, a very competitive result. Similarly, over that time frame for Express Scripts, EBITDA grew at a rate of about 50% greater than script growth. So what's the bottom line here or the point? Our ability to deliver attractive results is not limitedly tied to membership growth or script growth or employment levels alone. We grow because we secure client relationships led by either the strength of our medical capabilities or our pharmacy capabilities. We then work relentlessly to expand those relationships by identifying additional client needs, and we deliver specific products and solutions that address their needs. And when you step back and consider that health care has so much cost pressure, elevating health burdens and fragmentation, there is no shortage of opportunities to identify. As a result, we're able to maximize affordability and value for those we serve and are appropriately rewarded with ongoing attractive and sustained revenue and earnings growth. Now additionally, you may recall, when we announced our combination with Express Scripts, we said that combination was built on a framework of growth. Yes, profitable growth. However, we did not predict that we would expand margin. In fact, we said we'd keep it stable. I'll come to that -- back to that a little later. Now this is supported by our focus, for example, where we look at businesses that have lower fixed costs than a typical managed care owned delivery system or bricks-and-mortar pharmacy or clinic. At the same time, when we see aspects of care that we think are unique or differentiated, such as specialty pharmacy, behavioral or virtual care, we seek to own them. Our planned acquisition of MDLive is a great example of that. We also have lower amounts of capital that are encumbered by our regulated insurance business. For example, in U.S. Commercial, almost 85% of our customer relationships are in self-funded. And as an enterprise, more than 2/3 of our total revenue is generated from service businesses. This is what we refer to as our capital-light model. As a result of that, we've been able to return billions of dollars of value in savings, be they medical or pharmacy or the result of expense leverage back to our clients and customers in the form of affordability savings. And that has helped to drive ongoing superior top line growth and attractive sustained margins. These 2 fundamental strategies have and continue to support our growth across these platforms. Let me provide a little bit more forward-looking detail. For example, in U.S. Commercial, we currently have less than 10% market share in the Select segment, which I would remind you are employers with 51 to 500 employees. We will continue to grow this segment at a double-digit rate. The result, we'll double the size of it over the next 5 to 7 years. In the Middle Market and National Accounts segment, we continue to grow our addressable market by expanding the number of geographies in the United States where we have highly differentiated medical costs. You'll hear more about that a little later today as well. And importantly, we continue to innovate and deliver new solutions, which allows us to expand share of wallet with our clients and customers, delivering more value to them and attractive return for our shareholders. All of this is fueled by our ability to continue to deliver the best-in-class medical and pharmacy trend, which drives overall affordability. And you'll hear more about this shortly from Matt Manders and Amy Bricker. Now as I noted before, there's 2 primary ways in which you can establish or land a client relationship. They typically are built off of a medical foundation or a pharmacy foundation. And the results generated from our Evernorth suite of pharmacy solutions provide a powerful foundation to utilize [ TAD ] or other industry-leading capabilities, such as behavioral health. Evernorth is also meeting our client needs by continuing to offer flexible funding alternatives. And our approach continues to be to allow our clients to decide what financing mechanism works best for them because Evernorth is positioned and built to support a wide range of preferences and to do so profitably. For example, you recall that prior to 2018, less than 50% of our clients had full pass-through rebate arrangements. In 2019, we noted that it moved to just approximately above 50% of our clients that were in full pass-through relationships. As we step into 2021, we estimate that somewhere greater than 75% will be in full pass-through relationships. So as this example demonstrates, our results are also not tied to a particular tool or model. We're able to deliver the solution that works best for our clients and deliver attractive, sustainable earnings growth. So when you put it all together, when you consider the strength of our medical and pharmacy capabilities, we're able to establish strong long-term relationships. And as a result, this first building block of our growth framework, delivering differentiated value, we expect to account for about 2/3 of our ongoing revenue growth. The remaining 1/3 will be generated from ongoing partnerships and innovation and expanding our addressable markets. A couple of quick examples here. We expect, for example, our Medicare Advantage business to deliver ongoing 10% to 15% organic growth fueled in part by geographic and solution expansion. Additionally, in our individual and family plan business, we are systematically expanding from approximately 20% coverage in the United States to 40% coverage by 2025, thereby doubling our state footprint, again, expanding our addressable market. This type of market and product expansion, along with our ability to partner and innovate, fuels our sustained growth, not just in 2021 but over the long term. And again, you'll hear more about this from Matt, Tim, Eric and our team of presenters throughout the morning. Let me move to the second question. Here, I want to address the risks facing our industry, be they economic, legislative or political, and how our outlook will be affected. To ground us, our outlook is our base case. These are the results we will deliver. Underlying our base case are a variety of assumptions, and it starts with the fact that we know the environment's going to continue to be dynamic. And we see an environment where affordability continues to be the #1 need around the globe. We expect governments and employers, the primary buyers of health care, to continue to be actively engaged. We expect ongoing regulatory and legislative activity as well as significant ongoing technology and clinical, largely through pharmacology, advances to continue. In short, our base case recognizes there'll be both headwinds and tailwinds. Said otherwise, we do not require an ideal or optimistic set of conditions to achieve our targets. In fact, we know that environment doesn't exist. So this question comes down to how well could we withstand or we drive a meaningful downside scenario? Let me try to simplify this complex but very appropriate question by highlighting 2 major forces. Number one, does the U.S. employer sponsor market dramatically compress or ultimately disappear? And number two, does demand for pharmacy solutions dramatically compress? Or does the economic model change significantly on the accelerated basis? Now if you step back, the primary forces that would cause this are either disruptive, accelerated legislative or regulatory activity or new entrants that may come to the marketplace. Our perspective is that all markets and all businesses face headwinds every day that affect growth in margins, and it's incumbent upon a company to deliver more value and accelerated value every day. Additionally, to successfully offset these headwinds, you need to innovate relentlessly and smartly expand your addressable market. In addition to that and importantly, we have a number of levers that enable us to successfully navigate a dynamic environment. First is our orientation. Key here in our company is not to resist disruption but rather anticipate it and at times create disruption and capitalize on it. This is a foundation within our strategy. Then second is our ability to create strategic flexibility and have multiple avenues to both deliver value and capture value. This is made possible by our service-based model. It provides a significant amount of agility and nimbleness. Recall, I noted that in excess of 2/3 of our overall revenue is service-based. This creates flexibility. And we have been able to return billions of dollars of medical and pharmacy cost savings, which has fueled our growth and attractive margins in disrupted environments. We also are able to profitably grow and maintain flexibility of funding choices. Recall, I noted that full rebate pass-through moved from less than 50% to over 75% in less than 3 years, all while we continue to grow and deliver attractive margins. All of this underscores our ability to dynamically adapt our business model to address emerging challenges and opportunities even in the most dynamic environments. Third is our significant operating cash flow generation. Now this is made possible because of our capital-light model. In 2020 and '21 alone, we were able to generate $18 billion of operating cash flow, and that's prior to the divestiture of our group business. This creates a large and powerful tool to offset potential downside scenarios by allowing us to free up more capital and deploy it over the short term for shareholder value creation, whether it's in reinvestment in the business, target M&A or accelerated share repurchase. Our model also allows us to more aggressively flex our expense levels as we have a more variable expense base in our company. Now we have drawn upon these levers time and time again to withstand and even thrive in unprecedented uncertainty. For example, the ACA, creation of public exchanges, introduction of private exchanges, new entrants like Haven or disruptive purchasing consortiums and the threat of disruptive legislation and regulation for drug pricing as examples. During these events, we've been able to deliver on our promises for our clients, our customers and our patients and to our shareholders. The results, we delivered 15% EPS CAGR over a decade. Taken all together, we recognize there'll always be downside scenarios. However, we have the capabilities and orientation to adapt to an accelerated changing environment and uncertainty. And it's been tested time and time again, and this is what gives us confidence in our ability to continue to effectively respond to shifts in the landscape. Let me move to the third question. Here, I want to address the COVID impact and specifically the headwind of $1.25 we called out for 2021. First, to be clear, we expect this headwind to be transient and therefore recoverable. We believe and see vaccines will continue to be rolled out at an increasing level of efficiency throughout the course of the year, significantly lowering the number of and intensity of COVID cases. As we look to recover this headwind over 2022 and '23, we expect that medical costs will normalize over that time period. We expect the negative impact of Medicare Advantage revenue to be largely recovered in 2022. We further expect the U.S. Commercial revenue impact to be recovered across 2022 and 2023. Now to put this in context, we expect at least 3% more EPS accretion in 2022 because of our ability to recover a meaningful portion of this dislocation. Said another way, we expect to perform at or above the high end of our long-term EPS range for 2022. You'll hear a bit more about this from Brian later. So when you put all this together, Cigna is stronger and more resilient than we've ever been. And we've worked to keep our commitments over the last 2 years and importantly to position ourselves for another era of sustained growth and attractive value creation. So let me close with just a few headlines. First, again, we recognize the environment is disruptive, and we recognize growth does not come easily. We have to earn it. Two, we have a clear track record of delivering differentiated value even in the most highly dynamic environments. And as a result, we have attractive, sustainable growth opportunities across our 3 well-positioned platforms, executed through a durable growth framework designed to deliver differentiated value, leverage partnerships and drive ongoing innovation and smartly expand our addressable market. And importantly and finally, we have the strategic and capital flexibility to take advantage of these opportunities. I again want to thank you for being here. And now I'd like to turn it over to Matt Manders who will spend some time on the first critical element of our growth framework: how we are working to create even more value through affordable, predictable and simple solutions every day for our stakeholders.

Thank you, David. Good morning, everyone. I'm Matt Manders, President of Government Solutions. I'm pleased to be joined today by Amy Bricker, our President of Express Scripts, from our innovation lab in St. Louis. As you heard from David, delivering differentiated value in the form of affordable, predictable and simple solutions continues to be mission-critical for Cigna. This is our first building block of our growth framework that Amy and I will discuss with you today. We'll start with a focus on affordability, the top need of our clients and customers. Then we'll break down our affordability approach and demonstrate how by custom-designing solutions instead of just selling products, we drive down the cost of care and improve overall value. Then we'll discuss how our approach, which harnesses transparency, integration, coordination of services and value-based programs is driving real results. Finally, we'll talk about how this component of our growth framework drives 2/3 of our 6% to 8% revenue growth across our businesses. So let's dive in. Affordability is the #1 issue in health care with a need and urgency that has only accelerated in the past few years. There are several key drivers challenging affordability. Today's population is growing older and sicker with health risk and chronic disease on the rise. Gaps in quality and access to care continue to persist in part due to low utilization of high-performing providers and suboptimal sites of service. And ultrahigh cost therapies are rapidly entering the market, which further fragments and adds to the complexity of care. While many see a problem, we see the opportunity to address these root causes and radically transform the landscape, a purpose we embrace and a role we're well positioned to take on in health care. At our last Investor Day in 2019, we reset expectations that achieving industry-leading medical and pharmacy trend was not enough to transform affordability. We committed to delivering sustainable trend at or below CPI and since have delivered strong results as more than half of our largest clients are realizing CPI or better trend today. Now as we enter our next phase, we're intensifying our efforts to further improve affordability, pulling even more cost out of the system and proactively addressing future cost drivers. Our intensified affordability approach targets the largest components of client health spend and differentiates across 4 dimensions: one, by providing access to high-performing providers who deliver the highest quality of care; two, by lowering the cost of drugs; three, by guiding customers to the most effective sites of care; and four, by removing the fragmentation through end-to-end clinical solutions that bring together the highest-quality cost-effective providers and services. Before I go deeper into the 4 dimensions, let me set context on how affordability tools have evolved and been applied in the market. Initially, the market delivered clinical and benefit design programs. These programs are effective and now very mature in the market. Slowly, the market moved towards whole-person health, connecting and leveraging across medical, pharmacy and behavioral. We were on the forefront of this market shift, and that has propelled us to deliver industry-leading medical and pharmacy trends. Recently, shifts in consumer preferences and technology advancements have made the adoption of alternative care delivery both feasible and desirable. We're aggressively pursuing alternative care capabilities because this is a game-changing accelerant for each of these 4 value creators for affordability. Alternative care delivery does not present channel conflict for us unlike most of our competitors with existing bricks-and-mortar delivery models. This supercharges our ability to improve affordability and gives us a clear runway to drive trend that is even better than CPI in the future, with the potential to further raise the bar and deliver 0 or negative trends for our clients and customers. Let's now dive deeper into the first affordability dimension, providing access to high-performing providers. Our networks are designed to guide patients to high-performing primary and specialty care providers and at the same time continuously improve their cost performance. We partner with top performers across all conditions, and all of them offer more cost-effective and quality care choices. This ensures that the providers prevent adverse health events and that they make the appropriate procedural choices with their clinical interventions that help reduce out-of-network spend, unnecessary or redundant procedures. It also encourages utilization of the right drugs through medication cost transparency based on the customers' specific benefit design. Finally, it helps providers choose to render care in the most effective locations and to coordinate with other high-performing providers as care is needed, delivering the same or even better clinical quality. We constantly evolve our provider reimbursement models to incent and align along these actions. And this translates to material savings across our U.S. medical book. Customers save more than 10% on average when we connect them with high-performing providers. And this is critical from an employer perspective and translates to $250,000 of annual savings opportunity for a company with only 500 employees, thus enabling them to expand or reinvest in their people and their businesses. This work is additive to our value-based collaborative care initiatives that have a strong track record of aligning incentives, improving outcomes and lowering the total cost of care. Today, almost all value-based relationships across our U.S. medical networks meet or exceed the quality benchmarks. And this drives roughly 60% lower ER and hospital readmission rates than non-value-based providers. We also consistently maintain our partner of choice position in Medicare Advantage. The second dimension of affordability focuses on improving drug cost. Our pharmacy solutions increase the value achieved for each dollar spent on pharmaceuticals and drive to the lowest net cost, improving medication adherence and utilization and as well as applying the same value-based orientation to the pharmacy space that we use with our provider partners. We are the only player that brings to market dozens of value-based programs that incent and align pharmaceutical manufacturers based on the outcomes rather than consumption levels. These programs are built by therapy class, and we combine them with condition management or medical programs that we evolve as new therapies become available. Our teams provide specialized clinical coaching and lifestyle engagement tools that are powered by our deep data intelligence, which drive the highest therapy completion rates in the market. This approach has dramatic impacts across conditions. For example, in the inflammatory space, the #1 costliest drug class for the past decade, we reduced patient costs by $6,000 and saved clients $1 million per year. In addition, we target specialty and gene therapy costs that represent more than half of total drug spending. These costs are equally driven by unit cost and utilization. From a unit cost perspective, our strategic formulary construct drives competition in drug classes and captures the value of natural market opportunities. This includes the exciting advent of biosimilars. These are low-cost alternatives for high-cost biologic drugs that we believe hold incredible disruptive potential. These pharmacological innovations bring a unique opportunity to the inflammatory drug class in 2023 where the entrant alone will enable us to drive down cost by up to 30% per treatment. From a utilization perspective, we help manage treatment of high-cost drugs through Accredo, our specialty pharmacy, where we are uniquely positioned at the point of care. For many patients, this occurs in their homes, 95% of whom are within 1 hour of our 1,100 condition-focused pharmacists and field-based nurses. Accredo also impacts unit price as we are the undisputed partner of choice for drug manufacturers with exclusive access to more therapies than the competition and the only specialty pharmacy with both access to both gene therapies that are on the market today. The third dimension is about guiding customers to the most effective sites of care. We transform access to high-performing providers and administer medications across multiple footprints with a focus on virtual, digital and in-home alternatives. This is an extension of our previous site of service initiatives that guide customers from inpatient to outpatient to lower-cost traditional settings. In virtual, our virtual primary and urgent care solutions bring more choice to customers in need of timely and cost-effective access to care. Now we anticipated this demand well before COVID-19 and, as I mentioned, positioned ourselves early to meet customers where they want to be met. Our acquisition of long-standing partner, MDLive, will build on this foundation. Today with MDLive, we're already delivering: average medical cost savings of $425 per customer visit compared to in-person care; higher generic medication use through health plan formulary checks; better in-network referrals to cost-effective labs and specialists; and very importantly, high customer NPS of 71. We continue to move volume to lower-cost virtual alternatives to improve early identification, diagnosis and management of critical care needs. This includes expanding into post-acute and chronic virtual care and extending well beyond medical into behavioral, dental and virtual care with multiple new solutions that we have in the pipeline for 2021. Joan Harvey is going to elaborate on this point later this morning. In digital, our new provider directories and remote patient monitoring applications enhance the provider-patient interactions and better control chronic disease. Digital directories encourage virtual care first for the routine needs, and remote patient monitoring applications aggregate our pharmacy and medical data to improve medication management, safety and adherence. Now we leverage this across our health plan, government, employer and individual plans in U.S. medical and in our digital health formulary through Evernorth. In the home, our industry-leading solutions and assets bring providers and medications to the homes of our customers. This happens through eviCore, which connects to post-acute and complex care; and Alegis Care, which provides primary and chronic care to the growing seniors population. The fourth dimension of our affordability focuses on creating end-to-end clinical solutions that get ahead of the disease, treat both mental and physical health and close the gaps in care. First, we actively prevent adverse health events through early behavioral lifestyle interventions, consistently driving preventive care and virtual wellness business to identify issues like pre-diabetes and hypertension. This saves up to $3,500 per customer in future medical cost. Second, unlike others, we enable care that treats behavioral and physical health in concert. Why? Because mental health conditions like anxiety and depression are often left untreated, and they further exacerbate physical health. Our multiple medical and pharmacy programs address these issues together, saving clients more than $2 in medical costs for every $1 spent on behavioral. Finally, we develop condition-specific programs that target diseases with significant impact, such as behavioral, oncology, musculoskeletal, diabetes and rare orphan diseases. Our programs connect the full breadth of our capabilities to eliminate the fragmentation and to curate seamless care delivery. We touch every dimension of care creating specialized clinical pathways that are unmatched in the industry. And Amy's going to go deeper on this in a moment. So all in, our affordability approach inherently makes health care more predictable and simple. For customers, they experience more personalized guidance with on-demand digital access, they feel more informed upfront around the cost of care, and they achieve more savings because of their care decisions. For providers, this translates to a better understanding of customer needs based on our data with treatment costs, clinical interventions and benefit insights at the point of diagnosis and prescribing. And for clients, this results in best-in-class NPS because our transparent funding programs and choices help them best cover their costs, along with total cost of care guarantees. So in summary, we differentiate in the market by custom-designing solutions that maximize the value of our clinical programs, our value-based partnerships and our alternative care delivery capabilities. We achieve this across the intersection of medical, behavioral owned pharmacy, which drives meaningful value through affordable, predictable and simple health care. Now I'd like to turn it over to Amy who's going to provide a few examples to bring this to life for you.

Thanks, Matt, and good morning. We've highlighted several key areas central to driving value for our clients and customers. I'll start with our innovative pharmacy solutions that lower cost for customers with complex conditions. With diabetes, one of the most prevalent and costly chronic conditions, we have introduced breakthrough value-based partnerships with pharmaceutical manufacturers and programs that protect patients from high out-of-pocket costs. For example, our Patient Assurance Program caps the price of insulin at $25 for a 30-day supply, which on average saves patients 40% or more. This improves adherence by creating affordable access to medications, coupled with digital engagement tools that help patients take them as prescribed. We continue to advance these actions, expanding beyond insulin to include other diabetes drugs and encouraging the use of 90-day refills through our home delivery pharmacy and retail pharmacy partners. With 90-day refills, a focus that was further accelerated by COVID-19, we consistently increased adherence rates for diabetic patients by 26%. By keeping customers on potentially life-saving drugs, we produce material savings for clients, create better health for customers and leverage this approach to address other high-risk conditions where customers are exposed to significant out-of-pocket costs. Now let's go deeper into site of care and crosswalk the impact with pharmacy and episodic medical events. Our deliberate choice to embrace a wide variety of care delivery models without channel conflict concerns gives us flexibility to render care and administer medications across multiple lower-cost footprints. This is critical in the context of specialty injectables where cost of treatments continue to rise. We know we can make a measurable impact by driving utilization at the right sites of care, including provider offices, freestanding infusion suites and in the comfort of a patient's home through Accredo. Using injectables for multiple sclerosis as a proxy, we save up to $60,000 per patient per year by moving from a hospital setting to a provider's office and an incremental $4,000 by administering in the home. The same philosophy holds true for a range of invasive, surgical and diagnostic services that have high cost variability. This includes colonoscopies, endoscopies, knee replacements, among others. As Matt mentioned, our reimbursements are designed to help high-performing providers make the right procedural decisions at the most appropriate site of care. With colonoscopy and upper GI endoscopy, 2 of the most common procedures, we save $1,400 and $2,000 per customer by shifting to lower-cost centers and conducting follow-ups through virtual care in our U.S. medical networks. Now let me share an example of our end-to-end clinical programs that target complex conditions and connect the breadth of our solutions across critical moments of care. I'm going to tell it through the lens of a patient who is diagnosed with cancer. We recognize how overwhelming this diagnosis can be for a patient and their family. So we curate the best care options, guiding them from diagnosis to a return to health. This starts with leveraging eviCore's intelligent medical management capabilities that connect the patient to our oncology specialist partners for a second opinion. As our provider partners develop a treatment plan, we connect the patient with a dedicated oncology case manager who coordinates an entire care team. This includes a behavioral coach and services to help them cope with stress and anxiety, which can lower costs by up to $20,000 per year. The care team also features an oncology pharmacist and infusion nurse through Accredo, who manage medications and administer treatments at home, driving adherence rates that are well above the market. Finally, we provide access to partners who remove financial barriers or social barriers such as food delivery and transportation as well as survivorship services, return to work and retirement support that we coordinate with the patient's employer or health plan, our client. A cancer patient interacts with dozens of health care professionals throughout their journey, each with touch point that we use to connect through our benefits and intelligence to maximize value as their #1 trusted partner. As a result, we save the patient and their family tens of thousands of dollars per year while improving clinical quality and enhancing their overall health. We take the same approach across many complex diseases, knocking down traditionally siloed models to untangle the patient experience unlike the competition. Now I'll turn it back to Matt.

Thanks, Amy. Our efforts to make health care affordable, predictable and simple are delivering real results and high satisfaction for the customers, employers, government entities and the health plans that we serve. Let me give you a sense of the total impact. In the last 2 years, on top of COVID-related impacts, we improved customer engagement by 30% and delivered best-in-class NPS through our digital tools. We also closed gaps in care, creating average client savings of $4,800 for each customer with a health improvement opportunity. This represents 20% of a given population, translating to $10 million for a client with 10,000 covered lives. We also improved pharmacy costs by nearly 5% in 2019 and 10% in 2020 for clients who leveraged our most innovative suite of solutions. And finally, we improved medical spend by 4% for integrated clients compared to nonintegrated clients. These impacts, in aggregate, dramatically increase the quality of care and take billions of dollars out of the system each year. The market is directly feeling our value, and we continue to resonate with clients and customers around the world. Overall, our differentiated value drives 2/3 of our 6% to 8% revenue growth outlook. This is led by retention and further fueled by deepening and expanding new and existing relationships across target U.S. segments and global geographies. David talked about how our differentiation shows up for clients and customers. First, it's through point solutions from Cigna or Evernorth. Second is through coordinated services that connect multiple point solutions within our portfolio and from our partners. These services are offered with Cigna Medical or through Evernorth, where the medical benefit could be with another health plan. They fill a critical need among large employer and health plan clients who historically had to purchase disparate point solutions all on their own. We remove the complexity by aggregating and leveraging the right combination of point solutions so that they work seamlessly together, maximizing value across affordability, customer quality and, very importantly, the customer experience. The third is through integrated solutions with Cigna. So all of this enables us to pull through value to those with or without Cigna Medical across our growth platforms. In Evernorth, our growth is driven by the value we deliver through pharmacy, benefits management, care solutions and intelligence. This value feeds the entire enterprise and serves all buying segments. Key drivers of that growth include Accredo, where we continue to deliver more services to patients with rare and complex conditions, as well as eviCore with ongoing expansion, including across U.S. Medical. This also includes end-to-end clinical and value-based pharmacy programs in addition to new digital therapeutics and intelligence solutions that bring data analytics services across our client base. These industry-leading point solutions and coordinated services come together and build from our demonstrated track record of getting patients the right treatment at the best overall value. In U.S. Medical, our growth is driven by the value we deliver through integrated offerings. These offerings are enhanced by Evernorth point solutions that enable us to upsell opportunities with employers and customers. In U.S. Commercial, key drivers of that growth include delivering a network that gets customers to the right providers and sites of care, including virtual, digital and in-home alternatives as well as adding more pharmacy and condition-focused solutions. We continue to accelerate our trend reduction across employers in need of these comprehensive solutions, which is critical in the high-growth select segment that continues to move to more of a self-funded model. In U.S. Government, we are positioned for consistent growth in our Medicare Advantage and individual and family plan businesses in the geographies that we operate in today. Within Medicare Advantage, key drivers of growth include delivering superior clinical quality and strong Star ratings. This builds from the 88% of the customers in 4-star or higher plans and our partner of choice position with value-based providers. In addition, we continue to enhance our integrated PPO, HMO and supplemental benefits, invest in virtual capabilities that are rapidly being adopted by seniors and leverage our broad, affordable commercial networks and deep Evernorth pharmacy solutions. This translates to low premiums, competitively attractive plan benefits and greater care coordination with providers, which improves outcomes at lower cost for our individual customers. Our growth in international markets is driven by the value we deliver across supplemental, integrated and coordinated offerings, all deepened through our enterprise capabilities. Key drivers of our growth include expanded peace of mind solutions, which drive improved health and behavioral outcomes at better price points for our customers and clients; targeted health solutions that are offered to populations that have specific needs such as seniors with dementia; and enhanced access to care capabilities, which connect our globally mobile and domestic health customers with the highest-performing providers and care management programs across markets. This means we are putting enhanced, lower-cost solutions in the hands of more government, employer and individual buyers around the world. So in closing, we are delivering real value today for clients and customers through affordable, predictable and simple solutions, and will continue to drive and accelerate disruption in the market. Each of our businesses has a clear runway to grow with purpose and to capture market share while, at the same time, positioning our enterprise for future growth. With that, I'll hand it over to Tim Wentworth and Jason Sadler, who are going to go deeper on partnerships and innovation, which is the second building block of our growth framework.

Thank you, Matt, and good morning, everyone. I'm Tim Wentworth, CEO of Evernorth, joined today by Jason Sadler, our President of International Markets. David mentioned in his opening today that partnership and innovation are key to our growth strategy. This morning, Jason and I will expand on that point to show how our partnership and innovation orientation is at the heart of our strategy and will fuel growth across our enterprise. Today's health care landscape is complex, fragmented and rapidly changing. And against that backdrop, our clients and customers are demanding solutions that cut through the clutter to deliver affordable, predictable and simple care. From interoperable data to applied machine learning and robotics, we have new technologies at our fingertips that allow us to fundamentally change how health care is delivered, monitored and measured. There's no doubt that the challenges before us are enormous, but so is the opportunity. To achieve our purpose and meet the evolving needs of our stakeholders, we know we must be willing to challenge the status quo and to innovate on a scale and at a pace that is unprecedented in health care. Importantly, we also need to view innovation as a team sport. This is where the power of partnership comes in. We have decades of experience, partnering with diverse organizations in ways that provide value to the customer, value to our partners and, in turn, value to us. We have learned firsthand that the right partnerships raise the tide for all of us by putting more innovative solutions in the hands of more people more affordably and more quickly than any one company could do on its own. We've also learned that partnerships fuel our growth with purpose by expanding and accelerating our reach and our impact. With that in mind, our partnership orientation has 3 key strategic drivers. Specifically, we partner in instances where it will accelerate the pace of innovation, help us create mutual value and expand our addressable market. Today, innovation is one of the most overused words in business. Too many companies describe themselves as being innovative without much substance to back it up. At Cigna, we have a powerful track record of innovation, and that is a function of 3 key differentiated, tangible assets. The first is our capabilities. We have an extraordinary toolkit to innovate with. Our 3 growth platforms, U.S. Medical, Evernorth and International Markets, have capabilities ranging from medical benefits and management to pharmacy and care solutions, behavioral health services and data and analytics. Simply put, we have more dots than almost anyone in health care and a drive to connect those dots in new ways that truly differentiate us from our competitors. The second is our scale and distribution. For example, we have more than 175 million customer relationships and more than 1.6 million relationships with health care providers, clinics and facilities around the world. Through Evernorth, we serve over 300 health plans, 2,300 employers and 170 labor and government entities, all of whom count on us to be an innovative partner. Our size and reach gives us the ability to take an idea, bring it to life and execute it more quickly and effectively and at greater scale than almost anyone in the health care spectrum. That makes us a very desirable partner of choice. The third is our culture. We have a culture of innovation and a commitment to taking on the toughest challenges in health care. At Cigna, we test and learn and adjust at a pace not commonly seen in our industry. Our culture of innovation is embedded right across the enterprise with our Evernorth lab, where Amy is today, serving as a dedicated, state-of-the-art innovation work zone. Every day, teams of physicians and pharmacists, data and behavioral scientists, researchers, designers and developers come together to change health care from the inside out. 2 years ago, Cigna's combination with Express Scripts brought together 2 of the most innovative companies in health care. Both businesses had leading capabilities, meaningful scale and very aligned innovative cultures. But we quickly demonstrated that our combination would unlock even more potential. Together, we could bring innovative solutions to market more quickly and at a greater scale than ever before. Within months of the integration, we harnessed our combined capabilities to produce a number of industry firsts that delivered on our promise of greater affordability, predictability and simplicity. We leveraged our capabilities to introduce the Embarc Benefit Protection, shielding customers from the skyrocketing cost of gene therapies. Embarc brings together our health services, medical benefit management, risk management and specialty pharmacy expertise to make breakthrough medications more affordable and accessible for those who need them. We leveraged our capabilities and our scale to introduce the Patient Assurance Program, which Amy mentioned earlier, capping the price of insulin and providing immediate financial relief for patients. This revolutionary program was brought to market within just 100 days of the close of our combination. And we drew on our culture of innovation to create and evolve the industry's first-ever formulary for digital health apps and devices. With more than 300,000 health apps now on the market, we curated a formulary to help clients better navigate digital health tools and to coordinate many of them in unique, value-creating ways. We have a proven history of using our medical and pharmacy foundations to innovate in ways that few companies can. And our organic drive for innovation will continue to create significant new solutions for ourselves and the market. But partnership is also an enabler that allows us to innovate much more quickly and effectively than we could on our own. In fact, you could say partnership is in our DNA, and it's also at the heart of our strategy. We know that to deliver on our promise of affordability, simplicity and predictability, we must be the undisputed partner of choice for anyone seeking to make health care better. That starts with our own relentless focus on innovation, supported by our 2021 capital investment of $1 billion in capital expenditures devoted primarily to technologies that will support and help our growth. Our collaboration with others takes on a number of forms, ranging from partnership to co-investment and, in some cases, strategic acquisition. In 2018, for example, Cigna committed $250 million to Cigna Ventures to fund investments in promising start-ups and grow stage companies. Cigna Ventures serves as a periscope that allows us to monitor emerging trends and to invest in the companies whose innovations have the potential to address them. MDLIVE was a Cigna Ventures investment and is a perfect example of this concept in action. When virtual care delivery was still in its infancy, we partnered with MDLIVE to give members in our employee-sponsored health plans access to virtual urgent care services. 2019, we expanded the partnership to include virtual behavioral health. And in 2020, we added primary care services. When the pandemic started, MDLIVE quickly became the destination for virtual care, and we deployed hundreds of additional Cigna clinical colleagues to the platform to help meet demand. Our partnership with MDLIVE met all 3 of the strategic partnership drivers I mentioned earlier by creating neutral value, accelerating the pace of innovation and expanding our addressable market. Our acquisition of MDLIVE is a natural evolution, building on years of successful partnership and co-investment to arrive at a strategic acquisition that will create a core engine for our future state virtual care solutions. Oscar Health provides another excellent example of a partnership that has created shared value while allowing us to more expand -- more rapidly expand an addressable market. In 2020, when we wanted to broaden our reach into the small group market, our U.S. medical team structured a relationship with Oscar to provide coverage to small businesses. Our partnership with Oscar highlights Cigna's position as a company others want to partner with. We successfully launched with Oscar in 3 markets and have another 5 markets in the approval stages. And this gives us additional opportunities to explore new commercial solutions for small businesses such as our Cigna dental and vision products. It also positions us to grow and deepen our relationship through offering future innovative pharmacy, health management, behavioral and other health service capabilities. Next, there's probably no better example of a partnership that has accelerated the pace of innovation than the Vaccine Credential Initiative. Last month, we announced that Evernorth had joined with a cross-section of global health and technology industry leaders, including Microsoft and Salesforce, to develop a solution that allows consumers to access, store and share their digital COVID-19 vaccination records. One of the greatest priorities we all have is a safe return to school, work, travel and normal life as we know it. The Vaccine Credential Initiative brings together partners with the expertise to get us there as quickly as possible. Evernorth's leadership of this groundbreaking coalition is a direct result of our track record of innovation, our deep expertise navigating a fragmented health care system and, once the model is developed, our ability to drive adoption by tens of millions of people. We have deep experience in leveraging both partnership and innovation to elevate the health care experience of those we serve. Each has the ability to advance modern health care, but picture them as 2 circles in a Venn diagram. At Cigna, the area where they overlap is a significant accelerator to our growth and has the power to reshape the future of health care. To cut through today's fragmented and rapidly changing health care landscape, we knew we needed to create a dedicated platform, one that could harness the power of partnership and innovation to deliver on our strategy, and that platform is Evernorth. Evernorth positions us to identify, develop and deliver new solutions at a pace and on a scale that helps us to solve the biggest problems in health care while differentiating us from our competitors and fueling growth across our enterprise. Evernorth's value is in serving as a curator of best-in-class capabilities, often from within our own organization, but also coordinating and integrating with others from across the health care ecosystem, all for the express purpose of bringing meaningful and innovative products and solutions to the marketplace. That means at Evernorth, we have a relentless focus on data and insights to better understand the most pressing needs in the marketplace; speed of innovation by leveraging that culture of test, learn and adjust that I mentioned earlier; identifying value-add partners who bring additional reach capabilities or unique perspective that supplement our own; and helping our partners succeed. By doing so, we succeed. It all starts with our vast set of capabilities in pharmacy solutions, benefits management, care solutions and intelligence. These 4 pillars provide a strong foundation that allows us to identify key issues and gaps in health care and gives us the ability to innovate on our own to develop solutions but also that makes us an attractive partner of choice for others in the industry. Starting with our own capabilities, we are able to create partnerships that supplement and enhance our own perspective, expand our footprint and/or give us access to other best-in-class capabilities more quickly and cost effectively than we could build organically. This leads to highly beneficial collaborations across the health care system with health plans, as I will illustrate in just a moment, but also employers who see us as a true, strategic partner to help them achieve their objectives and thrive. In fact, our Health Connect 360 integrated patient dashboard, which is now helping to power over a dozen health plans, was first developed with large employers who were looking to improve health outcomes, productivity and targeted wellness results. We stepped up and delivered something that did not exist and solved their need. This is just one of the many examples where we meaningfully contributed to make an employer client's business better. Our collaboration can extend to others in the health care ecosystem who are sometimes even seen by others as competitors. For example, last year, we announced that our Inside Rx discount drug program would administer Amazon Prime's new prescription savings benefit, which gives Amazon Prime members access to low prices on many prescription medications when paying without insurance. It would be an understatement to say it was an unexpected collaboration by some, but that's what differentiates us in the market. Where some may see competitors, we see opportunities and new ways to win and grow. The same goes for our relationship with Prime Therapeutics. While we have a long history and strategic focus on partnering with and growing health plans, in 2019, when Prime went looking for a partner to help them grow their business, it was a highly competitive process. Prime is owned by a group of Blue Cross and Blue Shield plans. We earned Prime's trust because we deliver exceptional, sustainable, differentiated value, and we do it with integrity. We took on an additional 30 million lives across 23 Blues plans, collectively providing important health care to all of these Americans. Our relationship with Prime sent an important signal to the market. As a partner of choice, our express objective is to help our partners to succeed and to grow, and in doing so, we will benefit from their success. Importantly, as Prime worked closely with us, we built trust, and we earned the right to expand our relationship, leveraging our home delivery and Accredo specialty pharmacy assets to drive even greater long-term value. Evernorth was designed to bring together our vast array of health services capabilities as well as those we partner with across the health care ecosystem with the flexibility to offer them as coordinated, integrated or point solutions. As Matt outlined, solutions offered through Evernorth often represent stand-alone solutions that we can provide without the need to combine them with any other offering. However, with that as a starting point, the exponential power is in coordinating services in a way that meets a client's specific needs and makes each solution work more efficiently and effectively. For example, our new FamilyPath solution, which puts affordable, comprehensive fertility benefits in reach of millions of Americans. The demand for fertility coverage is growing. 6 million women are impacted by infertility, and by 2025, almost 10 million people will encounter fertility challenges. But comprehensive fertility coverage is rare. In 2018, about 80% of the people who underwent fertility treatments had little or no fertility coverage. We developed our FamilyPath solution to meet this growing challenge for families and employers using collective capabilities now housed all under Evernorth. This allows us to bring together comprehensive medical and treatment guidelines that support appropriate and cost-effective care; integrated pharmacy management and 24/7 support to help patients manage fertility medications and supplies, shipments and potential side effects; post-birth education and services to help set parents up for success; and behavioral health resources to help families with the emotional as well as the medical aspects of their journey. There is nothing else on the market quite like it, and we can provide it to employers as a stand-alone solution or to health plans as a private-label solution to integrate into their offerings, including offering it through our own U.S. medical businesses as an integrated differentiator. FamilyPath demonstrates clearly how the Evernorth platform uniquely positions us to solve an existing pain point for our clients and customers. But Evernorth's intelligence capabilities also enable us to use data and analytics to alert our buyer groups to problems before they land on their doorstep and enable solutions. The pandemic provides a perfect example of how we can apply machine learning and advanced analytics to generate intelligence that helps us see around corners for our clients and our customers. Our intelligence team analyzed the 2020 data gathered from confirmed cases of COVID-19 across our U.S. Commercial business to ask 3 questions: what happened, what worked and what can we act upon. The data showed that customers admitted to hospitals accounted for an overwhelming 80% of total COVID-related costs, but it also highlighted 2 important takeaways. First, hospitalized customers who had a post-discharge visit with a provider, either in person or virtually, and engaged with a case manager saw savings of almost $2,000 in a 60-day post-COVID period. Second, case management enabled an average return to work 7 days sooner, improving total cost of care while also supporting our clients with their productivity by getting their employees back to work faster. Evernorth's flexible model allows us to translate these insights into a coordinated COVID solution that leverages care delivery and case management to lower the cost of care and get people back on their feet sooner. So it's just one example of how our insights from our vast data pool can be used to pinpoint emerging issues for our buyer groups and how Evernorth can help us develop and refine solutions to address those issues. Evernorth will continue to bring to the marketplace an orientation that looks to future needs of the industry and our customers with the capabilities we have today serving only as a starting point. Our orientation toward partnership and innovation is key to our U.S. growth strategy, but it is also at the heart of our strategy for international markets. And so I'll hand it over to Jason Sadler now to tell us more.

Thanks, Tim. Tim did a fantastic job of illustrating how partnership and innovation are core to the success of our U.S. business. Well, I'm pleased to share this holds equally true for our international markets. In fact, partnerships have been at the foundation of our success across the 30-plus markets we operate outside the U.S. We have decades of experience working with a diverse range of partners that include banks, consumer finance companies, retailers and technology companies, helping them offer a diverse range of simple, affordable and predictable peace-of-mind solutions to their customers. Our 4 joint ventures in China, India, Turkey and, most recently, Australia have a deep history. They serve millions of customers and provide offerings that range from health and supplemental insurance to health services and data and analytics. These joint ventures are a great example of how partnership allows us to enter new markets, combining global knowledge with local insights and expertise that deliver innovative solutions to targeted customer segments in those markets. Now historically, we've played in 2 targeted segments outside the U.S., meeting the needs of the globally mobile and providing the emerging middle class across many Asian markets with a range of supplemental health solutions. However, our evolved growth strategy for international markets is going to see us focus on an expanded target set of customer needs beyond those traditional supplemental and globally mobile spaces. We see a growing opportunity to play more in domestic health and health services in a number of markets in which we operate. This is going to enable us to further expand our strike zone and go even deeper in those targeted markets. So in support of this, we've recently established 2 innovative partnerships. Both of these are capital-light and service focused, in line with the strategic orientation that David shared earlier. The first of these is in Australia, where we've created Honeysuckle Health, a specialist health care, data science and services company. This is a joint venture in partnership with nib Group, who are one of the leading health insurers in Australia. Honeysuckle utilizes data science to better understand people's current and future health risks and needs, actively helping them prevent, manage or treat those issues before they require acute care. And Honeysuckle leverages our established U.S. programs but applies them in ways that are locally relevant. They offer capabilities that range from discharge coordination, complex case management and behavioral health support. This is really at the center of our mission to address affordability whilst also ensuring care is simple, predictable. It focuses on the prevention of disease rather than the expensive, old-fashioned model of waiting until people are sick to cure them. We believe this kind of care coordination model can effectively and successfully be deployed across many of our markets. It's going to create incremental value for insurers, providers and customers. So over time, Honeysuckle will partner with a broad range of health care insurers and payers as well as health care providers to improve health outcomes for communities, both across Australia and New Zealand. But equally important, it's going to help us shape our strategy in other markets. And whilst this partnership was only launched 1 year ago, we've already achieved some compelling results. In just 1 program that focused on hospital readmissions, we were able to achieve a 17% reduction in a number of readmissions and a 25% reduction in costs. This not only drives better health outcomes, but it's a better customer experience and, of course, greater affordability. In the Middle East, in 2020, we extended our ability to play a broader, more substantive role in offering simple, affordable and predictable health care across the region. Our investment in NAS Neuron Health Services, who are the #1 third-party administrator in the UAE, account for 20% of all claims paid in the region, enables us to go even deeper into health services in this key region. And similar to nib, we'd actually partnered with NAS Neuron for 3 years prior to making this strategic investment. This allows us to further strengthen and deepen our relationship. The partnership is going to enable our Middle East business to drive closer alignment between customers and health care providers, leveraging technology-powered solutions that are going to drive efficiency and collaboration. And with a shared vision of proving the health system by enabling providers to improve care delivery and access, this is going to enable us to go even deeper with our customer relationships across the Middle East region. It's going to transform the care delivery model that puts the customer front and center. The range of current health services offered include telehealth, well-being programs, pharmacy benefit management, chronic medication programs, second medical opinion as well as data-driven tools, very similar to those used by Honeysuckle Health, thus enabling us to better support our customers in both remote and clinical settings. Now these are just 2 examples of numerous international partnerships that are currently driving innovation and enabling us to accelerate the delivery of health solutions across our key markets outside the U.S. They differentiate us from our competitors, and they enhance our capabilities to actively address the needs of our customers, clients and partners around the world. Tim, now back to you.

Thanks, Jason. As Jason illustrated so well, partnership and innovation are at the heart of our strategy globally, are in our DNA and will be the key to improving health care experience for millions more people around the world while fueling our expansion into new markets and our long-term growth. Knowledge sharing between our U.S. and international businesses provide a global lens on the emerging insights and technologies that can elevate health care for those we serve. Through Cigna and Evernorth, we have built a platform that enables us to innovate to meet the specific needs of each of our buyer groups. This, in turn, will connect us with more buyers and drive expansion into more markets. This approach and the strength of Cigna's existing businesses mean that we now have a value proposition for and a right to serve every major buyer group in the health care ecosystem. This gives us a great deal of headroom to grow in our existing markets, as Matt discussed, and to expand into new ones, as Eric Palmer will now address. So with that, I'll hand it over to Eric.

Hello, and thank you, Tim. While I know many of you from my most recent role as CFO here at Cigna, I'd like to introduce myself. I'm Eric Palmer, President and Chief Operating Officer of Evernorth. As Matt discussed, we're focused on delivering value to our customers, first and foremost, by addressing affordability, and that is fueling growth in our core. As you've just heard from Tim and Jason, our innovation and partnership orientation continues to drive our journey, making health care more affordable and simple for those we serve. David said it earlier. We have a real willingness and drive to take bold steps forward, to challenge the status quo and to advance meaningful change in health care. And in turn, this supports our growth and helps expand our reach across every buyer segment. Now, today, I'm joined by 3 colleagues: Joan Harvey, President of Evernorth's Care Solutions; Mike Triplett, President of U.S. Commercial; and Aparna Abburi, President of our Medicare business. And over the next half hour, we will discuss the deliberate actions we are taking to expand our addressable market in the U.S. over the next 5 years by expanding or deepening our geographic footprint and expanding our products and solutions and opening our products to new buyers. I'll come back to this grid at the conclusion, and we'll fill in these boxes with examples of how each business will expand the addressable market. Now while we're going to touch on U.S. commercial and Medicare Advantage shortly, I'll start by picking up the thread where Tim left off with Evernorth. In my new role, I am focused on growing Evernorth by further building our capabilities and creating more value for all of our clients. Evernorth is a health services business designed to serve all entities, health plans, employers, government organizations, health systems and provider organizations. We serve those that have Cigna medical insurance and those that don't. And in fact, approximately 80% of Evernorth's adjusted revenue is generated from clients and entities unrelated to Cigna, and our health plan client base is the largest in the industry. Our understanding of health care and flexible, focused solutions enables Evernorth to closely partner with clients and provide unmatched support that accelerates their respective strategies. I now want to focus in on 2 key areas within Evernorth, which will enable us to offer an expanded suite of solutions, broadening our addressable market opportunity. First, we're focused on building and enabling optimal care access capabilities, with a particular emphasis on virtual care. This is relevant because it not only significantly impacts affordability, but it also meets customers where and when they need care. Matt highlighted this earlier, is enabling virtual care will drive significant value by improving affordability. Providing care virtually also represents a significant opportunity for us to directly deliver care, and it is a high-growth focus area for Evernorth. And second, expanding our behavioral offerings to a broader set of buyer groups as our behavioral services were previously offered primarily through Cigna U.S. medical. There's a tremendous need for behavioral care solutions in the marketplace, and Joan will discuss this. Let's take a look at each. Now starting with building and enabling optimal care access capabilities. At Evernorth, we don't think about the marketplace opportunity as the U.S. insurance or the PBM marketplace. Instead, we look at the totality of the U.S. health care addressable market, which is $4 trillion, and of that, $2.5 trillion is in U.S. care delivery. That's a significant addressable market opportunity. And as David touched on earlier, we see meaningful opportunity to improve access and efficiency of care in this marketplace. Care models are rapidly changing, and we are positioned to continue to improve the value our clients and customers receive. We take an asset-light approach and do not intend to be in the business of bricks-and-mortar modes of care. Rather, we're committed to ensuring our customers and patients have simple access to convenient and affordable care when and where they want it. You're likely familiar with a number of our care access capabilities that address customer and client needs, both in home and on site. For example, by bringing together our capabilities addressing post-acute care in our eviCore business and our in-home primary care services in Alegis Care, we offer a full range of home care solutions to improve health and the care experience for our customers who have some of the most complex health needs. Today, a number of these capabilities operate in specific geographies, and we'll look to continue to expand those geographies as we look ahead. You've also heard this morning about our pending acquisition of MDLIVE and virtual care overall. So now I'll focus in further on how our innovation and virtual enablement will increase our addressable market, including the opportunity presented with the proposed acquisition. We all know that COVID has accelerated the change in how we define site of care and access the desire for alternative options and the rate of digital adoption. We expect a durable shift in the way consumers, providers and employers perceive and expect access to virtual care. As an example, this shift is particularly notable in behavioral health, where we saw a full 60% of our visits move to a virtual setting during the pandemic. That level has remained steady over the last year. We expect to see sustained growth in virtual care over the next decade. And with this as context, we see an environment where both the marketplace need for and acceptance of virtual care is growing, and our capabilities position us to deliver a broader reach of several types of care. We aim to enable virtual care well beyond today's telemedicine marketplace. We will deliver primary care, more coordinated chronic care services and coordinated behavioral services, all enabled virtually. We have positioned ourselves strategically to be able to pursue and advance the shift in care access with the positioning complemented by MDLIVE. And we're able to avoid the channel conflict many of our competitors have relative to needing to feed volume through existing fixed or bricks-and-mortar delivery models. Our focus on virtual care will lead to multiple benefits that fuel our right to win, including everything from early identification and diagnosis of critical care needs and better medication management that improves safety and adherence to more timely and cost-effective patient provider interactions and easy access to appropriate, lower-cost sites of service and pharmaceutical fulfillment. In short, we expect our virtual care capabilities to contribute meaningfully to our ability to improve affordability and offer a superior experience. This will ultimately fuel expansion, not only for the Evernorth addressable market, but also the entire enterprise's addressable market. Now I'll ask Joan Harvey, President of Evernorth Care Solutions, to join us to discuss how our behavioral services, as part of the care solutions portfolio, enables us to increase our addressable market. Joan, over to you.

Thanks, Eric. As you said, virtual care ties in closely with behavioral health. The connection between virtual care and behavioral health has never been more relevant than it is today. With COVID as a backdrop, 60% of our behavioral health customers are now using virtual services, and before the pandemic, 97% of these customers never had a virtual visit. And our proposed acquisition of MDLIVE will accelerate our ability to meet the very pressing mental health needs and provide timely, simple and more connected care. But before I dive in further, let me take a step back and provide context on Care Solutions. As a business, it includes medical, behavioral and clinical pharmacy programs as well as care delivery and care management services. These are all designed to meet the diverse needs of health plans, employers, government organizations and the people that they serve. As Eric noted, I'm going to concentrate on the opportunity in our behavioral health services. David spoke about key forces fundamentally changing the health care landscape, one of them being the greater recognition of the link between mental and physical health. Behavioral health conditions have a massive impact on our health care system. Before the pandemic, 1 in 5 adults were affected by a mental health condition, and U.S. spending totaled $225 billion. And COVID has triggered a second pandemic of behavioral health disorders, stressing an already strained system. The percentage of people reporting anxiety and depressive disorders skyrocketed from 11% to 40% in just a 1-year period. And substance abuse help lines saw an explosive spike in call volume over the past year, up nearly 900%. We can't ignore these trends, and we have a responsibility to help ease and provide easy and timely access to care for our customers. But this is also an opportunity for us to materially improve the system and bring to life what David spoke about earlier, our passion for growth with purpose. Based on our historical data and insights, as we look to see the future, we expect to see increased demand across all demographic groups for robust behavioral services, not only for depression, loneliness and anxiety, but also to treat and manage substance use disorders. As such, we expect presentation rates for outpatient behavioral health services to continue to increase in 2021 and into 2022. Before the launch of Evernorth, Cigna already had leading behavioral health capabilities, offering one of the largest virtual care networks with over 55,000 providers and was the only carrier to offer 24/7, 365-a-day year call center. While we have tremendous reach and impact within the U.S. Medical portfolio, we have a significant opportunity to tap into the total addressable market. As part of Evernorth, our behavioral business is broadening its reach, not only serving Cigna's U.S. Commercial clients but also health plans and other employer relationships providing behavioral health solutions through coordinated services. These services can include everything from access to care, navigation, high-cost claims management to integrating behavioral health and medical care, offering a fully customized suite of solutions to meet individual client needs while putting the patient at the center of the care equation. We are poised to curate services that address unmet buyer group needs. And we're able to go to market and connect with many of those buyers that already partner with Evernorth through Express Scripts, Accredo and eviCore. Our approach also helps us drive value-based reimbursement models for providers and offers performance guarantees to clients while improving patient and customer outcomes. And behavioral solutions will be a critical component of our coordinated services that help us expand the addressable market, solving for pain points and driving down cost while promoting whole person health. So as an example, one of the biggest buckets of health care spend lies in polychronic patients. They represent 5% of the population but drive 50% of the medical spend. This is because they have multiple comorbid conditions and require comprehensive condition management, behavioral services and palliative care. So with this insight, we brought together eviCore benefit and utilization management with behavioral services, in-home care, virtual care and our care coordination capabilities to drive down costs and improve health outcomes. As another example, we are seeing a rise in mental health issues among adolescents and young adults. We quickly pivoted to develop stand-alone solutions in this growing area. A final example lies in our development of end-to-end care solutions, something both Amy and Tim discussed earlier. We wrap behavioral care capabilities into these end-to-end care solutions, knowing that proactively treating behavioral health conditions reduces the overall cost of care. So these are just a few examples. But overall, in behavioral health alone, our addressable market has increased more than fivefold since we became part of Evernorth. And that is only the beginning. So it's a very meaningful, timely and exciting space. And I could certainly go on further. But given our time, I'll turn it back to you, Eric.

Thanks, Joan. The capabilities we've brought together under Evernorth, including behavioral services and care access within care solutions, positions us to develop services that address health care's biggest challenges and meet the needs of those we serve. Right from inception, these services are being designed to provide outstanding value to millions of people. Joan and I have highlighted some examples of Evernorth's opportunity to increase the addressable market. Now I want to turn to how Evernorth partners with our U.S. Medical platform to accelerate its growth and addressable market expansion. The businesses within U.S. Medical are already helping Evernorth to develop and are offering new Evernorth products and services to the marketplace. The deep level of partnership and collaboration ensures that our U.S. Medical teams maximize the value that Evernorth is able to bring to bear and are able to deliver sophisticated and comprehensive solutions to their clients that are tailored to meet their unique needs. Mike will talk about this more in just a moment. In essence, Evernorth powers our U.S. Medical business, fueling its growth. And in turn, the growth in our U.S. Medical business drives growth in Evernorth. So now I'll open this up to my colleagues to further discuss how we're expanding our addressable markets. Mike, let me start with you. As we heard earlier, U.S. Commercial has an incredible track record of growth, and you already have a national footprint. How will you continue to grow during what is a challenging time for many U.S. employers?

Thanks, Eric. We do have a strong foundation for growth, and we've had an impressive track record in our U.S. Commercial segment. Looking ahead, we're well positioned to build off of the strength of our differentiated value proposition as we will meaningfully increase our addressable market and continue to deliver attractive growth. So how will we do this? First, we're improving our competitive positioning across our footprint, thanks to the affordability strides Matt discussed, which gives us the right to win in more geographies and with more clients. Second, we're broadening our portfolio of capabilities primarily through Evernorth, which will allow us to expand our reach to new buyer groups, specifically those who are seeking greater flexibility and value from the coordinated services they purchase. And third, we're expanding partnerships in a unique and differentiated way to enable new avenues of growth. Let me discuss each of these briefly. Now throughout the day, you've heard about the multiple levers that drive our attractive affordability and industry-leading medical cost trend, such as our highly differentiated pharmacy offerings, including our best-in-class specialty pharmacy management, our deep partnerships with providers across our government and commercial businesses that drive higher quality and better outcomes and our world-class medical management capabilities. Now as discussed, we have a national footprint today, but we have significant headroom to further grow. And over the last couple of years, we've continued to improve our affordability position. Looking ahead, the combination of our improved affordability with our full suite of funding solutions, coupled with our deeply consultative sales approach, is a differentiator that will drive accelerated growth. It first starts down market as individual markets move to a more competitive cost position. Down-market employers tend to have a more concentrated customer base, so we see growth there first. And that's why, in part, we've historically been able to deliver double-digit growth in our Select segment. And post-COVID, we expect this to continue at the double-digit level. Now as more of these gains are made across multiple markets, it unlocks the growth potential with additional large employers with a multisite footprint. To put that into perspective, over the last 2 years, we've increased the percentage of the employer market where we are in a strong competitive cost position by 25%. And looking ahead to 2025, we're on track to expand that strong competitive footprint by another 25%. So we have tremendous momentum, and we will meaningfully expand our right to win in more geographies. And as our affordability position further progresses into a range of competitiveness, we will quote more business. And it will drive growth in the Select segment, middle market and national accounts. So let me make it real for you. We've always had a strong presence in Denver. But in the past couple of years, we have improved our overall affordability position even further not just in Denver but in key geographies across the state of Colorado. As a result, we can point to 2 large wins in the public sector and in national accounts that benefited significantly from our improvements in affordability. Our ability to be more competitive will enable us to serve more people in Colorado with affordable, predictable and simple health care not just through U.S. commercial but also in Medicare Advantage and individual and family plans, both of which broadened their geographic footprint in the state for 2021. So our improved affordability position gives us the right to win, which expands our addressable market.

Thanks, Mike. As I discussed at the top of this session, our growth platforms are interconnected to drive enterprise growth. How is U.S. Commercial partnering with Evernorth to expand the addressable market? What other partnerships would you highlight?

Yes. We're really excited about the opportunities Evernorth presents. As you and Tim shared, Evernorth developed solutions for large, sophisticated health plans. And we are both a strong partner in development and an early adopter of the innovative solutions Evernorth offers, which will create additional value, further differentiate us and drive growth. Evernorth will accelerate our ability to serve clients who are seeking greater flexibility through coordinated solutions to meet their needs, which will expand our addressable market. We'll use Evernorth's platforms and capabilities to enable connectivity and insights across solutions, unlocking incremental value for our clients, which no one is doing today. Additionally, we'll offer innovative solutions to help clients address health care's biggest challenges such as cancer. As Amy mentioned earlier, through Evernorth, we've developed a second opinion oncology solution. It's an industry first. So we're in a pilot period with over a dozen of our national account clients with plans to introduce it to other clients and other buyer segments. And finally, as Tim discussed, we are partnership-oriented. We found the right partner in Oscar, a competitor, to open a new buyer segment for us, the small group segment. This partnership will combine our complementary strengths and deliver integrated value through pharmacy, health management, behavioral and other innovative capabilities to a new segment of the market. While the growth in small group will be modest over the next several years, we will continue to expand our reach through new geographies in that space. The partnership with Oscar reflects our willingness to join forces with companies that many would view as competitors and to be disruptive with innovative and affordable solutions in an underserved segment. So when you put it all together: First, increasing our competitive footprint; second, serving an additional buyer group in a differentiated way; and third, leveraging innovative partnerships to expand into new marketplaces, we are well positioned to increase our addressable market by another 25% by 2025 and to continue to deliver attractive growth in U.S. Commercial. Clearly, we're excited about our path forward. Now let me turn it back to you, Eric.

Thanks, Mike. Let's shift gears to another area of U.S. Medical, our Medicare Advantage business, and Aparna Abburi, President of our Medicare business. Welcome, Aparna. We talked at our 2019 Investor Day about our growth plan for MA. Would you give us an update on how MA is growing and differentiating as we look to expand the addressable market?

Yes. Thank you, Eric. We're very excited about our room to grow in Medicare Advantage. As you know, we started on our accelerated growth journey just last year, and we remain confident in our ability to continue to achieve 10% to 15% Medicaid Advantage membership growth in the near -- next few years. It starts with our intense focus on geographic expansion. Over the past 2 years, we embarked on historic market expansion. Today, we currently reach 29% or approximately 18 million Medicare eligibles in the country with plans to reach 50% across the United States by 2025. We're committed to this continued geographic expansion, and we will do this by building on the strength and foundation that enabled us to expand into 67 new counties for 2021. We're also well positioned to reach a broader set of customers through our expanded suite of product offerings. We can offer customers a plan that best suits their preference, no matter their budget, health status or life stage, such as individuals aging into Medicare. We have a range of product offerings, including individual Medicare Advantage plans, Medicare supplemental products, prescription drug plans and employer retiree coverage or group MA, in particular. To give you an example of the power of providing customers with choice, consider Medicare Advantage PPO. In 2019, we offered PPO products in only 5 counties in 1 state, but we saw more and more senior selecting PPOs. And fast forward, for 2021, we're offering PPO products in 241 counties across 20 states and Washington, D.C. And this past annual election period, we saw high double-digit growth in these plans, and we're very excited about that. And third, we also view Employer Group Waiver Plans, specifically group MA, as an opportunity to expand our addressable market and further deepen our position as a partner of choice. Cigna's strong relationship with commercial clients is a significant leverage here. To your earlier point about how our growth platforms are interconnected across the enterprise, growth in group MA will bring associated revenue for Evernorth through Express Scripts, Accredo and eviCore and likely strengthens retention rates on commercial when a relationship is shared. Finally, we recognize the opportunity to improve the conversion rate of our U.S. Commercial customers who are aging into Medicare. We see about 150,000 Cigna commercial customers turning 65 years old each year. Raising our conversion percentage by adding geographies and refining our aging strategy creates further opportunity to fuel our MA growth. This growth will continue to be enabled by our industry-leading customer satisfaction and clinical quality measured by Star ratings. For 2021, 88% of our MAPD customers are in a 4-Star or a higher-rated plan, which positions us very well for continued strong customer retention and satisfaction, along with opportunities for expansion. We were the only major plan to show an increase in our Star ratings year-over-year. Additionally, our Net Promoter Score is also among industry leaders and has increased year-over-year for 4 straight years from plus 54 in 2016 to plus 74 in 2020.

Thank you, Aparna. Earlier, Matt discussed our approach to affordability and that it is a lever for how we deliver differentiated value. Would you share how affordability factors into growth and increasing the addressable market for the MA business?

Definitely. Affordability has always been a critical factor for older adults, and it's even more so now given the economic pressures brought on by the pandemic. Our strong business position, especially our industry-leading Star ratings I just referenced, has enabled us to consistently invest in our benefits over the years. And this makes us a competitive, attractive and stable option for customers. We especially provide a good value in difficult economic times. As a result, in 90% -- of 90% of our markets where we offer Medicare Advantage products this year, we show up in the top 5 of Medicare's Plan Finder tool, which reinforces the attractiveness of our offerings. Matt talked earlier about how we are driving affordability through our deep provider relationships. Today, nearly 85% of our Medicare Advantage customers are in value-based arrangements. We added more than 25,000 physicians to our MA network in 2020. And we are partnering closely with Mike's U.S. Commercial team to meaningfully grow in markets where we have well-established partnerships and a strong brand presence. By leveraging commercial relationships, we can make Cigna Medicare Advantage plans a top choice in new markets right from the time we launch them.

This is a great point because we've also deepened our breadth of talent and further refined our approach to strategic network contracting across our U.S. Medical businesses. Moving forward, this will continue to have a consistent impact and ultimately shape how we deliver value to our customers, clients and providers versus interacting with providers by specific lines of business. This will allow us to deepen value-based arrangements across the full spectrum of market offerings with our provider partners. When we show up as one company, the power of our brand is amplified, further accelerating growth, especially in those markets where we have Commercial, Medicare Advantage and individual and family plan offerings. In fact, we talked about our commercial and MA growth, but this approach is key to our goal of achieving double double growth in our IFP business by 2025. So we're projecting doubling IFP membership to 500,000 customers and doubling our markets to 20 states. It's another great example of how local market collaboration and alignment of strategies across business lines will drive growth.

That's so true, Mike and Aparna. When we show up together, we accelerate and deepen our right to win. And taking that a step further, as we activate that interconnectivity I talked about earlier among our platforms, we leverage growth across the entire enterprise and increase our addressable market. We've just covered a lot of ground. So in closing, I'd like to summarize and underscore using that chart framework I showed you at the top of how we're expanding our addressable market across 3 dimensions: Geographic expansion, product expansion and extending our reach to additional buyer segments. Each of these examples are meaningful growth opportunities on their own. Together, the opportunity set is compelling and presents tremendous growth opportunities for Cigna over the next decade. I'll run through this quickly across Evernorth, U.S. Commercial and Government markets. Starting with Evernorth. As we discussed at the top, we will continue to expand our in-home and post-acute care offerings across more geographies. We will bring new solutions in the form of virtual care and other innovations, and we'll grow by deploying our capabilities to new buyers, with behavioral care alone representing a meaningful opportunity. Within the U.S. Medical platform, Mike and Aparna broke down their respective businesses' expansions in detail. U.S. Commercial is poised to expand the addressable market by a combination of all 3, earning the right to win in geographies where we previously did not have a significant foothold, working with Evernorth to expand the solutions and services that attract new and deepen existing relationships and entering entirely new buyer group segments like small group. And within Government, there's a clearer growth strategy, partially driven by geographic expansion for both Medicare Advantage and the ACA market, new product offerings such as a range of affordable products and our PPO offering, and our increased focus on attracting new buyers, whether it be through the refinement of our age-in strategy for eligibles or leveraging our strong relationships with commercial clients. And although we didn't focus on international in this section of our discussion, as Jason mentioned earlier, we continue to innovate and grow there as well. With all of this as context, we expect our total addressable market in the U.S. to double over the next 5 years, from about $1 trillion today to $2.2 trillion in 2025. That is a 16% CAGR for our market opportunity. While expanding our total addressable market, coupled with our innovation and partnerships, drives approximately 1/3 of our projected long-term growth 6% to 8% average annual adjusted revenue, we remain enthusiastic about these areas as they provide us with the ability to pursue a variety of channels that will contribute to future growth. There's great opportunity ahead. Thank you, Joan, Aparna and Mike for joining this conversation. And now I'll hand it over to Brian Evanko to talk through our financial outlook.

Thank you, Eric, and good morning, everyone. I'm Brian Evanko, Cigna's Chief Financial Officer. This morning, we've highlighted the significant opportunities we see in our businesses. In my time with you, I will reinforce and expand upon 4 key messages that our leaders have brought to life across the day. One, we are purpose-driven and growth-oriented. This shapes our culture and informs our actions. Two, there are 3 fundamental forces changing the future of health care: Accelerated pharmacological innovation, greater recognition and acceptance of the connection between mental and physical health and rapidly changing access to care models. Three, each of our 3 growth platforms is well positioned to capitalize on these macro forces through our 3-pronged strategic growth framework of creating and delivering differentiated value for our clients and customers, partnering and innovating and expanding our addressable market. And four, we have a service-based, capital-light model, which drives compelling growth and attractive returns for shareholders. Over the next 25 minutes or so, I want to build off David's comments regarding some of the questions that are on your minds. I'll give an update on our 2021 outlook and go deeper into the impacts of COVID-19. I will lay out the long-term financial targets for our enterprise and each of our growth platforms, demonstrating how our strategic positioning allows us to drive and deliver continued attractive revenue and earnings growth along with strong margins. And I'll go deeper on how our service-based, capital-light business model and clear capital deployment framework generate compelling returns for shareholders and provide flexibility to manage through risks facing our industry. As I go through this, each one of these topics has a key item that I would like you to take away. One, we are well positioned to deliver against our 2021 financial commitments and achieve attractive 2022 results with 2022 adjusted EPS growth projected to be at or above the high end of our long-term range. Two, we are increasing our long-term outlook for Evernorth growth, given the numerous levers that are available to us and Evernorth's ability to capitalize on each of the macro forces we discussed. And three, we are fully committed to delivering long-term adjusted EPS growth that averages 10% to 13% per year, in addition to maintaining a dividend that will grow in the future along with our adjusted earnings. In addition to organic growth in our underlying businesses, we will deploy meaningful amounts of capital to dividends, share repurchase and strategic M&A. The combination of these deployment activities will create meaningful shareholder return opportunities. So let's start by spending a few minutes discussing our outlook for 2021. Last month, on our fourth quarter earnings call, we established our expectation for full year 2021 adjusted revenues of at least $165 billion and adjusted earnings of at least $6.95 billion or at least $20 per share. Today, we are reaffirming that guidance and remain confident in our ability to deliver on those commitments. 2 months into 2021, we have continued to see rapid changes in the broader environment. Newly diagnosed COVID-19 case counts and hospitalizations have declined meaningfully since peaking in December and January. This is a positive both in terms of lower direct COVID-19 costs and for the pace of recovery of the U.S. economy. Additionally, we've continued to see an inverse relationship between COVID-19 and non-COVID-19 utilization as individuals return to the delivery system for non-COVID-19 procedures when COVID-19 case counts decline. As we progress through the year, we expect these factors to continue to work in offsetting directions. We also announced our acquisition of MDLIVE just over a week ago, which is a great example of strategic M&A to further our growth agenda. And I would note, this does not materially change our expected deployment of capital that we outlined on our fourth quarter 2020 earnings call. Taken together, we remain confident in our ability to deliver adjusted earnings of at least $20 per share in 2021. Consistent with what we shared on our fourth quarter call, our outlook continues to include an expected COVID-19-related headwind of $1.25 per share. David walked through the components of this headwind at a high level, and I'd like to take just a moment to go into a little more detail. As a reminder, that headwind primarily impacts our U.S. Medical businesses and is made up of 3 components. First, the impact of elevated COVID-19 testing, treatment, vaccination costs and, to a lesser extent, revenue pressure in our Medicare business. This first component is about half of the $1.25 per share impact, most of which will be reflected in the medical care ratio. Second, lower customer volumes due to economy-driven enrollment dynamics. This second component is 35% to 40% of the $1.25 impact. And finally, the remaining 10% to 15% is due to smaller items that will show up in different parts of the company, none of which is individually material. While all of these components should ultimately be viewed as transient in nature, the exact timing of when each one goes away will vary. With the administration of vaccines, advancements in COVID-19 treatments and cyclical pricing adjustments, we expect approximately half of the cost impact from COVID-19 testing and treatment costs will be removed for 2022. And we expect our Medicare Advantage book to largely normalize next year from the quoting-related revenue pressure in 2021. And with our expectation of a gradual improvement in economic conditions, we expect that about half of the U.S. medical customer impact is recoverable next year as U.S. employment levels recover. Putting this all together, as David indicated earlier, we expect the transient nature of the 2021 COVID-19 headwind to generate at least 3% more accretion in 2022. And so we would expect to grow at or above the high end of our long-term EPS range in 2022 when compared with our current guidance of at least $20 of adjusted earnings per share for 2021. Now let's turn to our long-term framework. Looking across our organization today and through the lens of our proven track record of strong performance, we expect to deliver continued attractive growth across all of our businesses. Matt and Amy spoke about how we're able to grow our businesses through differentiated value of our solution services and capabilities, along with superior execution. All of this contributes to high retention, deeper relationships with clients and enables us to take market share in our existing target geographies and markets. Tim and Jason covered how through the partnership and innovation orientation of both Cigna and Evernorth, we're able to work nimbly and dynamically across the health care ecosystem, rapidly bringing solutions to market and driving value for our stakeholders. And Eric, Aparna, Mike and Joan discussed how we'll continue to effectively expand our addressable market through new solutions, services and capabilities and through targeting new geographies and expanding partnerships, enabling us to reach more customers and, in turn, serve more lives than ever before. Combined, these 3 building blocks of our growth framework provide multiple levers and opportunities to reach more clients, customers and patients and touch millions of lives around the world. And our growth framework directly fuels our long-term growth outlook. So let's dive into our long-term targets. For the enterprise, we expect to organically deliver 6% to 8% adjusted revenue and adjusted earnings growth on an average annual basis over the long term. Over the course of the day, we've walked through our growth framework, demonstrating how our delivery of differentiated value drives about 2/3 of our expected adjusted revenue growth, with the remaining 1/3 being driven by partnerships and innovation and the continued expansion of our addressable market. Going a bit deeper into our long-term targets by business. In Evernorth, our long-term expectations are to deliver average annual adjusted revenue growth of 4% to 6%, adjusted earnings growth of 4% to 6% and to deliver strong adjusted pretax margins of 4.5% to 5.5%. In Evernorth, our growth will be driven by: First, the continued delivery of differentiated value in pharmacy services, innovative utilization management programs and clinical solutions and industry-leading specialty pharmacy capabilities; second, innovations such as Embarc Benefit Protection and our Patient Assurance Program and partnerships like the ones we've established with Amazon with Prime Therapeutics; and third, the expansion of our addressable market by enabling alternative care delivery options, expanding care solutions, especially behavioral offerings, to attract new buyer groups and expanding data and analytics capabilities. And over time, these solutions will grow in relative contribution to our earnings. As Tim outlined earlier, Evernorth is comprised of 4 strong platforms: Pharmacy services, benefits management, care coordination and delivery solutions and intelligence. As David detailed, pharmacy is 1 of our 2 foundational relationship anchors from which to build out a broader services offering and a deeper relationship with clients. And from this foundational relationship, we expand our set of services to meet each client's unique needs. Further, our pharmacy benefits management relationships have continued to evolve. As David cited, prior to 2018, less than 50% of our clients were in full pass-through funding arrangements for rebates, and that has now grown to greater than 75% of clients today being in full pass-through rebate arrangements. This is a clear demonstration of our ability to offer flexible funding arrangements to clients to meet their evolving needs as we continue to deliver differentiated value at scale in the market, driving sustained earnings growth. You've also heard today about our Accredo specialty pharmacy's industry-leading capabilities and a strong market opportunity in front of us, as specialty generics and biosimilars continue to offer opportunity to deliver affordability to our clients and customers. Specialty pharmacy comprises approximately 1/3 of revenue today for Evernorth and has been growing at a double-digit rate. We see significant runway to continue driving that growth as pharmacological innovation drives further need for our solutions. Underpinning all of our services and our solutions is our relentless approach to improving affordability through partnership and innovation. Tim shared how our affordable solutions and our innovative approach led to the launch of our partnership with Prime Therapeutics, and we were able to initiate that partnership through our pharmacy benefits management offerings. As we worked with Prime and demonstrated our value, we were able to expand that relationship to include our Accredo specialty pharmacy and Express Scripts home delivery services, which we'll onboard across the course of 2021. We also have significant growth opportunities beyond traditional pharmacy benefits. Specifically, care solutions, intelligence, medical benefits management and other nonscript-related pharmacy solutions represent areas for accelerated growth in the future, as you heard earlier today from Tim, Eric and Joan. Much of this will be driven by expanding the addressable market for Evernorth into new solutions. Based on the differentiated value we deliver, our expanded services offerings and our broader addressable market, we have increased opportunity for growth in Evernorth, leading to an increase in our long-term outlook compared to our previous expectations as we now expect adjusted revenue and adjusted earnings growth of 4% to 6%, up from our previous expectation of 3% to 5%. Importantly, we expect adjusted earnings growth across all 4 Evernorth growth pillars. Turning to U.S. Medical. Our long-term expectations are to deliver average annual adjusted revenue growth of 9% to 12%, adjusted earnings growth of 8% to 11% and to deliver strong adjusted pretax margins of 9% to 10.5%. Within U.S. Medical, our growth is driven by U.S. Commercial and U.S. Government. And importantly, we will continue to provide insight into our expectations for each of these businesses. In U.S. Commercial, our long-term expectations are to deliver average annual adjusted revenue growth of 8% to 10%, adjusted earnings growth of 8% to 10% and to deliver strong adjusted pretax margins of 12% to 14%. U.S. Commercial has a demonstrated track record of strong performance. Prior to 2020, we drove 10 consecutive years of organic Commercial customer growth. And through the economic disruption of 2020, our customer base remained resilient, with disenrollment driving just a low single-digit percent impact. And in the Select segment of employers with 51 to 500 lives, we drove 5% full year 2020 customer growth as our compelling solutions drove ongoing strong new sales, along with continued strong retention. And as we go forward in U.S. Commercial, our growth will be driven by: First, the continued delivery of differentiated value that's rooted in our proven approach to driving affordability through the 4 dimensions that Matt and Amy referenced earlier. Second, ongoing innovation and partnerships like the one we've established with Oscar Health. As Mike discussed earlier, that allows us to provide affordable, predictable and simple health coverage to small businesses. And third, the expansion of our addressable market by improving our competitive positioning across our geographic footprint, giving us the right to win in more geographies with more clients. In U.S. Government, our long-term expectations are to deliver average annual adjusted revenue growth of 12% to 15%, adjusted earnings growth of 12% to 15% and to deliver adjusted pretax margins of 4% to 5%. Our U.S. Government outlook is particularly focused on delivering outsized growth in both Medicare Advantage and in the individual and family plans or IFP business. And as we go forward, our growth across both our MA and IFP businesses will be driven by: First, our continued focus on delivering differentiated value with affordable solutions and high clinical quality, along with strong customer satisfaction. Second, deep delivery system partnerships that are focused on health outcomes instead of claim volumes. This incentive alignment is at the core of our physician engagement models. And third, the expansion of our addressable market as we continue to both enter new geographies and expand our product offerings. As Aparna and Mike discussed, we have significant room to run in both MA and IFP as today, we address just 29% of Medicare eligibles and 20% of the IFP market with a path to expanding our MA offerings to 50% of Medicare eligibles while doubling our IFP state footprint by 2025. Going a little deeper. In MA, in 2019, we laid out a path to achieving 10% to 15% average annual customer growth over the long term. And in 2020, we delivered the first down payment on that accelerated MA growth journey with 18% full year MA customer growth. Today, we've reiterated that long-term 10% to 15% target. And we are well positioned to continue to deliver average annual customer growth of 10% to 15% in both 2021 and the subsequent years. For our Medicare Advantage customers, our differentiated value is rooted in our ability to drive strong cost and quality outcomes, earning all-time high Stars ratings with over 88% of our customers in 4-Star or greater rated plans as well as all-time high customer satisfaction, as demonstrated by our exceptional Net Promoter Score of plus 74, as Aparna discussed earlier. And in IFP, 2021 marks the first year of our accelerated growth journey. While we have exited the legacy non-ACA business, we expect ACA customer growth for on- and off-exchange business to be in the low double digits. And today, we shared with you our plans to more than double our customer base by 2025 through doubling our state footprint. In international markets, our long-term expectations are to deliver average annual adjusted revenue growth of 8% to 10%, adjusted earnings growth of 8% to 10% and to deliver strong adjusted pretax margins of 11% to 13%, driven by expanded health solutions and a broader addressable market through partnerships and alliances. And as you've heard throughout today's presentations, each of our businesses are uniquely positioned to capitalize on and further drive value through the macro forces of accelerated pharmacological innovation, greater recognition and acceptance of the link between physical and mental health and rapidly changing access to care models, which are fundamentally changing the health care landscape. Our strong growth in each of our businesses gives us confidence in meeting our long-term enterprise targets of adjusted revenue growth of 6% to 8%, adjusted earnings growth of 6% to 8% and adjusted after-tax margins of 4% to 5%. Turning to our capital priorities and framework. As David and others have mentioned today and as evidenced in our financials, Cigna's highly flexible, capital-light structure generates significant cash flow from operations. We've intentionally structured our service-based company to be in businesses that have low capital requirements rather than focusing on assets that have significant physical infrastructure needs or concentrated in capital-intensive insurance products. And with the sale of our group disability and life insurance business to New York Life, we've taken another important step to focus our company on health services offerings in a very capital-efficient manner. As David mentioned earlier, more than 2/3 of our enterprise revenue is generated by service businesses. This also helps us to drive a competitively differentiated SG&A ratio. And we have a model that's less reliant upon fixed assets like bricks-and-mortar care delivery, allowing us to return more savings and deliver more value to our clients and our customers. This capital-light, service-based framework also allows us to flex rapidly during times of change as it gives us significant financial and strategic flexibility. Looking at 2020 and 2021 combined, we expect to generate almost $18 billion in cash flow from operations over this 2-year period. And looking to the longer term, we expect cash flow from operations to grow directionally in line with our earnings. And from 2021 through 2025, we expect to generate cumulative cash flow from operations of approximately $50 billion, giving us significant financial capacity. To frame our intended uses of this powerful cash flow, our capital priorities are focused on continuing to reinvest back in our business to enable growth, returning value to shareholders through a meaningful quarterly dividend, executing strategic M&A to drive business growth and returning value to shareholders through share repurchase. This first priority, reinvesting in our business, we view as foundational. Specifically, we expect capital expenditures and surplus to fund growth to comprise approximately $10 billion out of the $50 billion in cash flow from operations that we'll generate across this 2021 to 2025 period, with some potential variability year-to-year depending on our internal investment priorities and business needs. We will deploy the remaining approximately $40 billion of cash flows from operations, net of internal uses, through dividends, strategic M&A and share repurchase. And regarding the dividend, we've oriented around the payout ratio in determining our dividend payments. Our target is a payout ratio of approximately 20%, as we would intend to grow the dividend in line with adjusted earnings growth over time. With this framework, we expect the dividend to comprise approximately 20% of cash flow from operations net of internal uses. Our final 2 capital priorities, strategic M&A and share repurchase, we see as somewhat fungible. On a combined basis, we expect to deploy the remaining approximately 80% of cash flow from operations, net of internal uses, to these 2 priorities. Over the longer term, we expect deployment to be split approximately equally between share repurchase and M&A. However, in any given year, this will vary as we assess M&A opportunities in the marketplace as well as the attractiveness of share repurchase. To put this into perspective, looking at 2019 and 2020, we deployed approximately $3 billion per year on average to dividend, share repurchase and M&A activities. And yet we also delivered on our integration priorities and deployed significant capital to achieve our accelerated deleveraging target. But as we go forward, we have considerably more deployment capacity and expect that the dividend, share repurchase and M&A will comprise approximately $8 billion per year on average from 2021 to 2025, more than 2.5x the level of deployment from the prior 2 years, driving growth in our business while creating significant shareholder value. We also consider all of our levers as we position our company from a capital perspective. As we've discussed, we finished 2020 with a debt-to-capitalization ratio of 39.5%, delivering on our commitment to delever to a ratio of less than 40% within 2 years of closing on our combination with Express Scripts. As we move forward, we will target a debt-to-capitalization ratio of approximately 40%. At times, this ratio may rise above that target as we pursue targeted M&A. But over time, we expect to manage to approximately that 40% target. Importantly, the cost of our debt has declined meaningfully in recent years with a more than 20% decline from 2014 to 2020 for interest expense per dollar of debt, while the weighted average maturity of our debt has increased over that same time frame. While specific uses of capital will vary from year-to-year, this capital deployment framework will guide our actions. Our capacity to execute against all of our capital deployment priorities is a testament to the ongoing growth and the strength of our businesses and our ability to generate tremendous cash flow from operations both now and into the future. And it demonstrates the efficiency of our capital-light flexible framework. We'll complement organic growth by selectively pursuing M&A opportunities that are strategically aligned and financially attractive. Broadly, we're focused on opportunities that will accelerate our strategy by delivering leading capabilities, expanding our reach in addressable market and/or building scale. And our 4 priority areas of focus are aligned with our business strategy of providing more affordable, predictable and simple health care. And these areas are: one, care coordination and alternate sites of care delivery capabilities; two, government programs and services; three, intelligence and technology capabilities for customer decision-making and health care interoperability; and four, expanding our international health care capabilities and footprint. Our recently announced acquisition of MDLive is directly linked to this first M&A priority. Ultimately, M&A is one tool that we have to grow and develop our business, and we'll purposefully and intentionally leverage it. Additionally, we intend to organically reinvest in our business, partner for growth and invest in early-stage ideas and technologies through Cigna Ventures to position our company for success over the near, intermediate and long term. So stepping back. As we leverage our powerful cash flow generation through our capital deployment framework, we expect accretive capital deployment to drive average annual adjusted EPS growth of 4% to 5% per year. And we are additionally currently returning almost 2% in dividend yield to shareholders through the recently announced meaningful quarterly dividend. In aggregate, this is driving a 6% to 7% expected average annual return on just our capital strength and efficiency. So bringing this all together, we have a very strong long-term shareholder value creation framework. I highlighted earlier how each of our businesses is positioned for organic long-term growth, building to an enterprise expectation for average annual adjusted earnings growth of 6% to 8%. Our intentionally built capital-light framework gives us the ability to drive an additional 4% to 5% of average annual adjusted EPS growth through accretive capital deployment. And that combines to drive our expected 10% to 13% average annual adjusted EPS growth over the long term. This is both a reiteration of our prior long-term adjusted EPS growth target and a stronger overall total shareholder return opportunity, given we are now paying a meaningful dividend. As David said, we have a strong track record of delivering consistently attractive results over time with 15% average annual EPS growth over the past decade, delivering above our long-term target of 10% to 13%. And we're confident we will continue to deliver on our outlook going forward. So as we wrap up, I want to reiterate that Cigna continues to lead the way to address the trends that are changing health care. Our businesses are well positioned today and in the future to capitalize on these macro trends and thrive during times of change. Our growth framework positions us for sustained, differentiated growth under a variety of scenarios. And we have the cash flow to further fuel our business and our strategy, creating even more opportunity for attractive shareholder returns. This gives us confidence in delivering on our guidance of at least $20 per share in 2021 and on delivering against our long-term growth targets while generating significant shareholder value. So with that, I'll turn it back over to Alexis, and we'll open it up for your Q&A.

Thank you, Brian. I'd now like to invite David to join you with the appropriate social distancing, and I'd like to welcome the rest of our leaders back virtually as we move to an approximately 40-minute Q&A session. One quick note as we transition to Q&A, should any of you have had issues accessing the webcast or had any broadcast issues this morning, a full replay of this event will be available on the Cigna Investor Relations website this afternoon. Our slides are also now available on the site for viewing. [Operator Instructions] With that, let's jump right in. We'll take our first question from A.J. Rice with Crédit Suisse.

I just wanted to ask about some of the interaction that was discussed between International and Evernorth. A couple of aspects to that. International has made partnership arrangements with people outside of health care, you mentioned retail and financial institutions and so forth. Are there opportunities in the U.S. for Evernorth to pursue similar types of arrangements here? Are you looking at that? And then what about the opportunity for Evernorth to support the International operations? Is that on the drawing board? And then my final aspect to that question is, for the first time, I think International is listed as a priority for M&A. Can you just expand a little bit on that? Do you see that as mostly tuck-in deals? Or are there larger opportunities out there?

It's David. So I'll start by answering your question. I'll ask Eric Palmer to talk a little bit about the Evernorth opportunities. Unfortunately, we have a data feed issue with Dubai right now. So I'll take the international piece of the conversation. Specific to your last point, we've always had international as 1 of the 5 M&A priorities. So I would just highlight that piece of the equation. There's been consistency there, and we've been very targeted relative to the use of M&A successfully within our international portfolio. As it relates to opportunity, we do see service opportunities, as you articulate in both directions, especially sharing our global learnings. Secondly, as we care for the globally mobile population. And third, as we expand our services, for example, with Honeysuckle. There's an opportunity to take the informatics or intelligence capabilities that we have and some of the predictive indicators we have relative to health care outcomes and play them through our international operations. So I'll kick it over to Eric Palmer and ask him to pick it up from there through the Evernorth lens. Eric?

Thanks, David. A.J., nice to see you. Just a couple of other things I would underscore. First of all, as we think about the opportunity for Evernorth and international markets, I think there's a commonality in terms of the partnership theme that plays through both. And so again, I think there's good alignment in terms of the approach to problem solving and the approach to tackling the challenges in each market. I wouldn't call out additional international opportunities for Evernorth in the near term. But certainly, there's an opportunity where we can leverage Evernorth's assets to further drive the growth within the International segment over time. So again, think about that as a bit of a longer-term opportunity as we look to the future here.

We'll take our next question from Josh Raskin with Nephron Research.

So my question is more on the physician enablement sector and sort of how you're working with providers and specifically primary care physicians to capture more of that value. I heard you talk about moving to virtual to actually provide the care. But how does that expand to in-person care? And then again, specifically on your partnerships with primary care?

Jeff, I'm going to ask Matt Manders to pick up on this question in a moment. But as you articulate, the partnership dimension is mission-critical. And as you articulated in your question, the enabling dimension. So we see the opportunity to further expand partnerships, use our proven value-based care orientation and then the complementary nature of bringing virtual to bear as part of the equation as we go forward. And we've been successful both in Medicare Advantage, our individual as well as our commercial program. So Matt, I'll hand it over to you.

Sure. Thanks, David. And good morning, Josh. It's good to see you. As David mentioned, our focus around value-based care and our relationships, so we believe the front door care is predominantly through the primary care physician. So therefore, that has been a cornerstone of our business model around value-based arrangements, particularly, as you know, and a part I mentioned, 85% of our Medicare Advantage customers are accessing care through value-based arrangements. And very importantly, we've carried that heavily into our commercial business model also. So Josh, what I would ask you to think about is a continued focus of the organization on primary care through value-based arrangements. Very importantly, seeing the virtual aspects as complementary. Once again, one of the key tenets of our affordability approach is having care delivered with the best practitioners who deliver the highest quality from that context and a continued expansion and involvement with us in that space as we go forward.

Thanks, Matt. And just maybe to end with an anecdote. Today, we have essentially approximately 90% of all of our customers of patients we serve within a 10 to 15-mile radius of a high performing, value-based relationship in our portfolio. And that's something taken as well to work towards. So a very positive outcome for our customers and patients. Thank you.

We'll take our next question from Ralph Giacobbe with Citi.

I wanted to ask a little bit about the guidance. You mentioned the 3% more accretion in 2022. As I think about the $1.25 in transient COVID cost, that's 6 percentage points. So I guess the question is, is it a way to think about half of that coming back in '22 and the other half in 2023? Then the other part of it is you boosted the Evernorth up to 4% to 6% growth from 3% to 5%. But again, no change to that 10% to 13%. So I guess I'm struggling with that range. Is it fair to think that it's going to go -- be accelerant above that 10% to 13% range over the next 2 to 3 years? Or help frame where offsets may be.

Sure, Ralph. I'll just summarize real quickly and ask Brian Evanko to take both important points to your question. I would just highlight, we are delighted with the performance of the portfolio and specifically the Evernorth portfolio. We delivered 2 very strong years to put us in position to enter 2021 and our next era of growth very successfully. We're pleased to increase the top line outlook for that portfolio. And as the team walked through, we have multiple meaningful growth opportunities within the portfolio. I'll ask Brian to take both the COVID depiction as well as our aggregate growth profile. Brian?

Ralph, appreciate the question. And broadly speaking, in terms of the 2021 to 2022 bridge that you were walking through, your math is about right. So we anticipate about half of the $1.25 COVID-19 headwind returning in our 2022 financials. As you heard me say earlier, that translates to about 3% accretion, specifically to 2022 in comparison to our 2021 expectations of at least $20 per share. And again, that translates through then to our 2022 outlook being at or above the high end of our 10% to 13% long-term EPS range. To your point on why with the higher Evernorth growth opportunity, we don't see an increased opportunity in totality for the 10% to 13%. I would remind you, we're now paying a meaningful dividend that we previously were not paying. So you can think of close to 2% yield on our current stock price in addition to a 10% to 13% earnings per share outlook that we're now looking for over the longer term. So those 2 components in totality provide a significantly larger total shareholder return opportunity.

And just to summarize one additional point on the back end. As we noted, we have a track record of delivering on our commitments, and we're proud of the fact that over the last decade, we delivered a 15% EPS CAGR. So these are targets we expect to achieve or exceed over the long term, and we're proud of our performance here.

We'll now take our next question from Justin Lake with Wolfe Research.

A couple of things here. First, in terms of 2021 in the second half, I'm wondering what you're thinking about around deferred utilization for next -- for the back half of the year. And then relative to normal, do you think it's going to be 102%, 103% of normal. And then what are you building in for -- what do you expect to build in for 2022, given that deferred utilization uncertainty? I'm thinking about businesses like Medicare Advantage that have to price early in June of this year. And then if you could just -- if I could add something there, if you could just give us some color on your thoughts around Medicaid specifically, in terms of thinking about M&A and what you expect there, I'd appreciate it.

Justin, it's good to see you. I'm going to ask Brian to take the first portion of your question, and then I'll come back after that and take the Medicaid portion of the question. I would highlight, as you articulate, we have a few months ahead of us between current state and when some of the bids for 2022 need to be placed, and we recognize the fact that it's going to be another fluid year in 2021 to be able to make those estimates. But there's another few months between now and the actual bid cycle. Brian?

Justin, I appreciate the question. So as you're articulating there, the assumptions heading into the back half of '21 and 2022 continue to be fluid, first of all. And as David said, we have a few more months before we submit our bids for the government business. And our commercial book, as you know, has a rolling renewal schedule. So we'll be contemplating the most recent data that we have at any given point in time. So I'm not going to give you specific numbers in terms of what we anticipate for 2022 at this juncture. But broadly speaking, you can expect that we're going to be using the most current data that we have at any given point in time. One thing that I think is important for you as you contemplate where we are relative to 2021. The last 5 to 6 weeks, new case counts for COVID as well as hospitalizations have come down pretty meaningfully across the country. And we've seen that same dynamic come through our commercial book and our Medicare book. And as I said in my prepared comments earlier, we continue to see an inverse relationship between COVID-19 activity and non-COVID-19 activity, but it's a directional piece of good news the fact that case counts have come down and hospitalizations have come down over the last 5 to 6 months. So that gives us -- 5 to 6 weeks. So that gives us greater confidence in our ability to reiterate our 2021 outlook this morning of $20 per share. David, on the Medicaid?

Thanks, Brian. Just relative to Medicaid. You recall, our prior M&A priorities, we had 5 priorities. And the fifth one we always made reference to were state-based risk programs. That was a category we oriented around, and we'd always describe it as we believe, over time, states would be seeking to take a subset of the population that had potentially higher clinical challenges or otherwise the need for coordination of services and seek to get performance-based programs attached to those. As we refreshed our M&A priorities that Brian walked through, he talked about government programs and services. So you should assume that Medicaid expansion to the extent we pursue it through M&A will be in that category. Point 2 is we believe that and we see already through our Evernorth portfolio of services, we have and continue to grow the services we are offering and delivering, for example, to health plans relative to supporting Medicaid operations, and we see that as a growth subset within the Evernorth portfolio. So taken as a whole, we see Medicaid as a growth opportunity over time for our organization, specifically through our already well-stocked and proven Evernorth portfolio of services and then potentially over time through M&A, more likely toward the risk base or polychronic more challenged population where we think we could deliver differentiated value.

We'll take our next question from Kevin Fischbeck with Bank of America.

Just wanted to ask. I think most people think about Evernorth as being primarily a pharmacy benefit manager, and you guys spent a lot of today talking about a diversified suite of services that you guys are providing. I was wondering if there's any way for you to kind of quantify how much of Evernorth is actually kind of PBM as we normally think about it versus these other types of services and maybe how that might evolve by 2025.

Sure. Eric walked through in his prepared remarks a little bit relative to the expanding addressable market. So I'm going to ask Eric to take your question. And then maybe transition over to Joan, who spent some time talking about a subset of it, our care coordination and care delivery aspect of it, as an example of where we see significant demand. So Eric, maybe you could describe the breadth of our portfolio and then transition to Joan to give a little bit more color relative to the behavioral opportunity?

Thanks, David. Kevin, as I think about Evernorth and I highlighted in my prepared remarks, we've got quite a comprehensive set of capabilities already assembled. Now some of them are in different stages of maturity so the growth rates off of those different elements of the portfolio will be different just because of that starting point. Clearly, we do have scaled capabilities in pharmacy, and we expect that to continue to grow. In particular, expect there to be growth in the specialty pharmacy capabilities. We have such a tremendous pipeline of opportunities in terms of new therapies and needs coming and the opportunity for us to continue to drive more in specialty will be one dimension. So that pharmacy portfolio, think of that as large, but still a growth driver, in particular, a growth driver within the specialty capabilities. The second category I'd call out then would be our care and care-related capabilities. And Joan will click more on this in a minute. But the opportunity set that exists through virtual care, care coordination and care enablement is really meaningful. I mean so think about that as a high-growth opportunity for the Evernorth portfolio as well. Then think about our benefits management businesses, where I noted in my prepared remarks, we've got the opportunity to continue to build that platform and capability as well. And then last but not least, the intelligence capabilities that really both fuel all of our insights but also have growth capacity in and of themselves as well. So it's again, think about each one of those working with each other to drive distinct differentiated value. Joan, maybe if you can click a bit deeper?

Thanks, Eric. Certainly, Care Solutions has a tremendous opportunity to provide accretive value. And as I discussed earlier, our behavioral services organization is poised to increase this addressable market fivefold as part of Evernorth suite of services. We know that proactively treating behavioral conditions reduces the overall cost of care, and we are poised to curate those services to address those unmet needs of buyer groups. Many of those buyers are already partners with Evernorth through Express Scripts, Accredo and eviCore. In fact, we just met with a large employer client last week who was part of a large purchasing coalition. And they really wanted to understand how we could bring new and novel ways to integrate behavioral services into their existing pharmacy services and how end-to-end solutions could create accretive benefit and value as well. So our behavioral solutions are critical to creating coordinated service offerings that help address that expandable market and promote whole person health. Thank you.

Thanks, Joan. Thanks, Eric. And one thing I would just put a capstone on this is, recall, our positioning is such that we're able to establish a strong and durable relationship with a client either now through a medical offering and then bring additional products, programs and services or through pharmacy offering. And when you step back and think about it, largely, those are the 2 foundational programs that clients typically establish. And then having the breadth of tools and capabilities and earning the right to expand those relationships has been key to our success and will be key to our growth on a go-forward basis.

We'll now take our next question from Ricky Goldwasser with Morgan Stanley.

So David, just to expand on the point that you just mentioned. If we think about the discussion today, you focus on the end-to-end integrated pharmacy and medical and behavioral. And you also talk about Evernorth providing not just the opportunity to cross-sell into existing membership but also to extend into higher growth unregulated revenue streams. So how should we think about balancing these opportunities between monetizing externally versus internally? And also, if you think about it, appetite of ASO clients that in the past prefer to carve out some of the solutions that you're building at Evernorth, how can you see that appetite to potently carve them back in and the opportunity there?

Ricky, good question. So I'm going to ask Tim Wentworth to take the first part of it and come at it through the coordinated benefits and then transition over to Mike Triplett, who will orient around the integrated piece. The headline is choice, though. As the team comes at this, we've positioned our company to afford even further expanded choice for clients, be they clients who want a fully integrated portfolio of services or clients that want point solutions and multiple point solutions tethered together or coordinated in a way to deliver differentiated value. And our company, through the Cigna medical portfolio and the Evernorth portfolio, is positioned to avail that choice to our clients. So Tim, maybe pick up on the coordinated aspect and then transition to Mike to take it into the integrated aspect, please?

Sure. Thanks, David. And thanks, Ricky, good to see you or hear you. In fact, as David said, we are a choice-based architecture. And what's really important is it's being driven, in every case, by the strategy of our client whether the example Joan just used, which was a large employer that is trying to drive a particular element of their benefit strategy or a large health plan who are looking to take a coordinated solution out into some of their market, whether it's their ASO market or their self-insured market. What we're able to do is configure solutions that coordinate and create more value and make it, frankly, a little bit more turnkey for that end buyer to put into place. You may recall, for example, if you look at pharmacy, we, for years, have integrated with Livongo. And we didn't just integrate so that we were 1 plus 1 equaling 2. We integrated so that our pharmacists were getting the real-time information that Livongo was also receiving, and we were able to counsel patients using that seamlessly. The payer didn't have to weld that together. The patient didn't have to weld that together. We had welded it together, working with them and with clients in our lab to respond to the need that we were seeing in the market. And more importantly, validate the value that was created by what we did coordinating in that particular case. We've got a great platform across all of the aspects that Eric just talked about earlier to then integrate or coordinate, depending on the buyer, in a really meaningful way. In the case of our own health plan, our U.S. health plan, as Mike will share with you, we obviously are able to build solutions that integrate really effectively to meet the needs that Mike and his team identify in the market groups that we compete in. And so Mike, I'll turn that over to you.

Thanks, Tim, and thanks for the question, Ricky. This really expands what I would call our reach into a new buyer group. That buyer group is really a group that is seeking greater flexibility, more innovation from the services that they purchase. It allows us to broaden really our portfolio of capabilities via Evernorth. Evernorth will approach these potential partners really in an unbiased fashion, in an unconstrained fashion. You would think about these type services that are typically sold to national account clients. But also clients who are in the middle market. So as we're able to deliver that additional value, we will consistently continue to sell integrated offerings. We've traditionally sold integrated offerings, and we will continue to do so. But these buyers or buyers that are seeking maybe more point solutions or a little more innovation or a little more flexibility. So it will open up additional buyer group to us to allow us to sell those type products and services. We're extremely excited about the opportunity. And as being a part of U.S. commercial, we will be a strong partner of Evernorth in the development and in the adoption of those early solutions that are brought forward in the marketplace. It really is a way for us to bring more value to our customers, bring more differentiation to our customers and enable us to further grow. Thank you.

Mike and Tim, thanks. So just to maybe end on that final point, if you think about the Select segment that our team made reference to, you have a fully integrated offering there. We continue to grow significantly in that buying segment. And the value of that fully integrated offering continues to be strengthened as new innovations are driven through our Evernorth portfolio of services, helping us continue to deliver differentiated affordability. That's how the model works. Thanks for the question.

We'll take our next question from Steve Valiquette with Barclays.

Great. So within the ASO or fee portion of the commercial book, some of your large competitors have recently discussed the greater penetration and market share of ancillary services within ASO to improve their own profitability. And you touched on this topic for yourselves earlier today, but can you talk maybe in greater detail about your own ASO or fee-based commercial profitability, which may already be best-in-class, but how much further you can improve that profitability and penetration within your offerings as part of your outlook for 12% to 14% pretax margins in your U.S. commercial segment?

So Steve, I'll start, and I'm going to ask Mike Triplett to pick up the opportunity to further deepen the relationships from a self-funded standpoint. But to remind us of the context, approximately 85% of all of our U.S. commercial customers are self-funded today. Second, the deepening of relationship has been and continues to be a fundamental part of our strategy and a successful part of our strategy. Because by deepening that relationship with additional products, programs and services, that enables us to essentially not only earn more for a shareholder, that's a manifestation of us delivering more value to the client and customer. And that shows up in best-in-class medical cost trend on a regular basis. So Mike, I'll ask you to talk about the dynamism of how the client-by-client interaction outside of the Select segment takes place and then how the interaction with the Evernorth portfolio of colleagues will present new tools, new programs and services to cross-sell, to penetrate, to deepen relationships. Mike?

Yes. So thank you for the question. Really, as you think about it, in our prepared remarks, we talked about the 10 consecutive years of strong organic growth. We also talked about the 10 consecutive years of double-digit growth in the Select segment. And we'll continue to do that post COVID. When I think about our ASO offerings, it really is about our ability to continue to invest in our capabilities, in our people, in our innovations, in our service. This is not just about, I'm going to call it, a funding mechanism or a chassis. It really is about the ability to deliver results back to customers and clients, either through medical cost trend or through closing gaps in care or through higher quality and value through our value-based arrangements. It really starts with our highly consultative sales team that we consider to be best-in-class in the industry to work with our clients each and every single time on an individual basis. So we believe clients are all individual and really have a unique and a differentiated set of needs. So then it's to find the right solution for those from the multiple exponential combinations of levels of the integration that we have. And then to put the right funding mechanism around that. Potentially, that funding mechanism is ASO. And then we work countlessly to look at understanding their culture and their health burden and their overall strategy and their willingness to change. And then we work internally with our 7,000 clinicians to take all the touch points and data and analytics and those type of things to make sure that we're absolutely engaging and producing the right results for each of these clients on a go-forward basis. So we feel very comfortable as we look at our path going forward. Even if you think about the Select segment, it's an addressable market of about 40 million clients. Today, we have about 2.5 million of those clients. And so we think there is further opportunity and further room to grow on a go-forward basis.

Thanks, Mike. So again, to summarize, it's a cornerstone of our orientation with our clients, whether it's through the U.S. commercial relationship, or through the Evernorth relationships to identify opportunities, to expand services to deliver more value to clients, customers and patients. And as a result, be rewarded successfully. And we have a track record of doing so. And through continued onward partnership, innovation and delivery of value will continue to drive us on a go-forward basis in all of our portfolios. I appreciate the question.

We'll take our next question from Matthew Borsch with BMO.

Yes, I was hoping maybe you could talk about what priority you're putting on acquisitions in Medicare Advantage. And maybe as part of that, you can talk to what is the gating factor for expanding your market -- sorry, the total addressable market that you're facing? I know you have a good plan there in 2025. What would prevent you or make it tough for you to accelerate that?

Matthew, so I'll start, and then I'm going to ask Aparna to pick up your question and talk about our organic path. But back to our growth strategy within our MA portfolio is an organic first strategy and a successful organic first strategy. It may be complemented over time with inorganic activity. As Brian synthesized, it remains one of our M&A priorities for our portfolio. Now you articulate expanding our addressable market. Our geographic expansion, our product portfolio expansion and then the ability to more successfully harness some of the volumes that exist in the market, for example, in terms of agents within our commercial portfolio, all present very attractive growth opportunities. So I'll ask Aparna to give you a little bit of a frame of the exciting path she and the team have in front of her over the next several years, Aparna?

Thank you, David. Matthew, as David said, we have a very thoughtful approach to how we are going into new markets. There are multiple factors that kind of influence how we think about staging which markets come in, in which year. We -- as I mentioned earlier, we are only covering about 1/3 of the country, and we still have a lot of room ahead of us. Some of the factors that I'll double-click on that really influence how we think about our market penetration. The relationship is on the commercial side, right? There's -- the 85% of our MA public is really in those value-based relationships with the providers. So we really want to make sure that that plays significantly into how we think about our market priorities. David said about the aging population. We have 150,000 Cigna commercial clients turning 65 every year for the next foreseeable future. So that plays significantly into how we think about the market prioritization. So there are a number of factors, such as those things that really help us inform how we stage the markets and how we go into each of these markets. So we're very proud of the 18% growth we saw in 2020. And we have every confidence that we can continue to expand our geographic footprint and add additional products, especially PPO and keep adding the new geographic markets.

Aparna, thank you. So Matthew, you maybe put the fine point on wrapping this up. On the organic path in front of us, the only item that gates us is actually our own rate and pace and remaining focused. We're rather a disciplined organization. So we want to remain focused as we open up new geographies because we typically do them with more advanced provider partnerships, ideally through the value-based relationships you heard Aparna make reference to. But the team is extremely excited around the growth trajectory that sits in front of us in MA.

We'll take our next question from Scott Fidel with Stephens.

I had a question. I want to touch a little bit more on the target to double the individual and family plan membership in 2025. I thought that was notable. Actually maybe just breaking down a couple of the drivers of that, that you think that could occur. And maybe first, if you can talk about how growth would be driven by expanding into the new markets that you talked about as compared to looking to gain market share in existing markets. And then also, just as we think about the mix of that growth between individual market growth and then small group, no individual is a considerably larger book of business for you currently. So -- but you did flag, for example, the Oscar relationship in small groups. So interested if you think over the next 5 years, if the balance of growth may be a bit more, let's say, balanced between individual and small group are still more weighted towards individual.

Sure, Scott. It's great to see you. I'm going to ask Matt Manders to pick up that question and talk about our posture thus far in the individual and family plan and our discipline and our excitement in terms of the geographic footprint expansion that will take place to achieve that double-double over the time frame. And just to front run it, the majority of what the team is talking about there is largely through the individual programs. We see the small group Oscar partnership opportunity as an additional opportunity above and beyond that. So I'll summarize that on the back end after Matt talks about the individual market. Matt?

Thanks, David. Scott, thanks for the question. I appreciate it. So first of all, we're very excited about the individual and family plan space. As you know, we have continuously participated on the exchanges since they were launched. And we've taken a very measured, very thoughtful and very disciplined approach. As Mike Triplett talked about earlier and the genesis of your question here is, we have set a double-double goal. So essentially, we want to double the state geographic footprints as well as double our customer base between now and 2025. From that context, you're asking in terms of the generation of the customer base. A significant portion of it will continue to come from the markets that we participate in today. But also a material amount will also come through the new markets that we will be entering. One point I would just really want to stress. As we approach this, we see this as a great opportunity for profitable growth for the organization. As you can imagine, as we're doing the expansion, we're leveraging our positioning and our presence from our -- both our commercial and our Medicare Advantage books. And then also very importantly, we've been involved in the exchanges since exception, and we have deep learnings from this, Scott, and really understand what the customer needs are and very importantly, how to be successful here. So we're very excited that this is an accelerated growth path for us as we move forward.

Thanks, Matt. And briefly on the small employer piece of the equation. Mike Triplett referenced in our formal remarks, the opportunity that we have in that marketplace in partnership with Oscar. That's a great example of seeking to be the undisputed partner of choice. We're able to take some of our capabilities and their capabilities and bring some new offerings to the market. And as Mike noted in his prepared remarks, there'll be slow continuous growth there, but then some additional growth opportunities as we look to the future. And importantly, that presents another value proposition for our team when they sit down with our health care provider partners to drive local density of relationships and help us further improve affordability for the benefit of all the clients and customers we serve. Scott, thanks for the question.

We'll take our next question from Dave Windley with Jefferies.

I wanted to come back to virtual care. The -- this first generation of telemedicine providers has created an important access point. You touched on that earlier in the comments. It has also -- has become more mainstream, threatens fragmentation of care, and we started to hear more commentary around longitudinal care. I wanted to know how that fits in your thinking as you bring MDLive into the fold. Is MDLive well positioned to facilitate and support longitudinal care? And then somewhat separately, is MDLive -- or how is MDLive positioned or will it be positioned to potentially feed growth into other parts of Evernorth, like pharmacy, specialty pharmacy, things like that? So I'll stop there.

Sure, Dave. You packed a lot in there. So congratulations, I think you have the most dense question of your colleagues for the morning and a really important topic. So what we're going to do is I'm going to ask Matt Manders to talk a little bit about the way in which we see the ability to leverage the capabilities within virtual care and what we've learned to date and then we will take it forward. I'll ask Matt to carry it across to Eric Palmer and have Eric talk about the way in which these capabilities will be part of Evernorth and provide expanded services for our clients and customers. And then, Eric, I'm going to ask you to bring it over to Amy to talk a little bit about the importance of another touch point with clients and customers and patients around gaps in care around pharmaceuticals and how our TRCs and other capabilities will be able to leverage that even further. Matt, to you?

Thanks, David. And Dave, thanks for the question. So first, I'll start off. We've had a long-standing relationship and partnership with MDLive. They have, up until this point, predominantly supplied urgent care as well as some elements of primary care and then also some elements of health and wellness and preventive care for us on this context. And it's really translated very well in terms of access. It's translated very well to lower cost sites of care, higher generic medication utilization and better and improved in-network reference points and directive points as well as, as we've talked about in our prepared comments, really strong customer experience from that perspective. As we look to the future, and you recall in my prepared comments, talked about 4 major affordability dimensions that we're pursuing. We actually see that MDLive will be an accelerant across all 4 of those dimensions. So specifically, we see leveraging this asset combined with the existing assets within the organization of really driving longitudinal primary care, chronic care, complex care, and very importantly, you heard Joan talk about behavioral care. So from that aspect, it's very, very complementary in terms of the capabilities we have and will serve to be a really critical element from an affordability perspective. Let me turn it over to Eric, who'll talk to you about the growth opportunities here.

Great. Thanks, Matt. As I think about MDLive, there's a couple of key points I want you to take away from the overall messaging here. First of all, we expect and we'll position MDLive to work -- to be a growth driver in the pursuit of the affordability that Matt just talked about. But it will be a growth driver in partnership with our U.S. medical business. It will be a growth driver in partnership and collaboration with our Evernorth clients as well. And to think about, MDLive will be positioned as one of the capabilities within Evernorth to be a growth driver. And we do think that MDLive will be an integrated approach. And so there will be opportunities in terms of all of the Evernorth businesses interacting seamlessly with one another and working to drive additional value through that interconnectivity. As I noted in some of my earlier remarks, we have the Evernorth portfolio positioned to work together, fueled by data and insights. And I think the effective use of the data and the insights and the capabilities we have within the intelligence platform will prevent there from being the fracturing of care that you described in your -- tee up your question. We don't see that as -- we see that as a challenge that we'll be able to work through by having the right interoperability, the right flow of information and the right protocols in place and how we work with our delivery system partners and our clients' delivery system partners. So we would drive to use the virtual care capability as an accelerator of exchanging of information rather than one that fractures information. I can go on, but I'll let Amy dive in a bit further in terms of some of the opportunities that exist specifically in the pharmacy and specialty pharmacy space. Amy?

Thank you. And to round out this question, Express Scripts has assembled the largest number of value-based programs in the country. We're very successful with respect to those programs because of our therapeutic resource centers that are central to Accredo. So when you think about MDLive as another asset within Evernorth, we think about that as a further connection within the ecosystem for us to track patients and to interact with not only the physician elements, but also the patient in a more seamless way. And so we're already thinking about how we can look to additional therapeutic options, an expansion of our SafeGuardRx programs to name one area.

Amy, Eric and Matt, thank you very much. Suffice to say, a lot going on here. We see it as complementary and extension of the delivery system. We see it as an opportunity to have more coordinated care and services. And it will be an asset and set of capabilities like many of the assets and set of capabilities in our portfolio, we'll continue to invest in and innovate and evolve on a go-forward basis.

Thank you. That concludes our Q&A session, and I'll now turn it back to David for closing remarks. David, please go ahead.

Alexis, thank you. First, let me start with, again, appreciation, as I did with our opening. We appreciate you prioritizing the session and spending your time with us today. We know how busy you are, and we appreciate your ongoing interest in Cigna. I also want to thank my team. Hopefully, get a flavor of the energy, passion and knowledge to guide our corporation on a go-forward basis. I simply want to leave you over the next few minutes with 5 thoughts to wrap up our session. First and foremost, we recognize that growth does not come easy in any way, shape or form. It has to be earned. So to do so, you need to be forward-looking. And we highlighted 3 fundamental forces of change that we think are well at work in the health care delivery system and health care environment and well-being environment going forward. Pharmacological innovations will be the backbone of innovation in health care. The greater acceptance of mental and physical health is a coordination opportunity and rapid evolution of access to care. As a corporation, we seek to embrace, leverage and position ourselves to take advantage of those forces of change for the benefit of those we serve. Point 2 is we convert it through 3 well-positioned growth platforms: first, Evernorth, our health services suite of portfolio and capabilities; second, our U.S. medical portfolio, which has commercial and U.S. government; and then third is our international markets portfolio of capabilities. Each one of which is well positioned for ongoing significant growth. Point 3 then is a durable growth framework that will guide our company going forward, and it starts with the foundation, delivering differentiated value to those we serve. That helps us earn the right to have elevated retention; earns the opportunity to expand relationships as many of the questions took us back to with smart targeted services that deliver differentiated value to our clients, customers and patients; and then ultimately, our ability to add new business to the portfolio. Then second, we work relentlessly to innovate and then seek to expand partnerships to support new products, programs and services. And in some cases, those partnerships fuel the third priority, which is to expand our addressable market. And we had many opportunities today to discuss expansion opportunities to our addressable market. My fourth point to leave you with is we have key differentiators. And you had a flavor of those differentiators through our capabilities, our products, our programs and services. So I'll just highlight 3 points. One, we're a purpose-driven organization, and we have a purpose-driven growth orientation within our portfolio, and that transcends our capabilities around the world; two, we've worked hard to position our company with strategic flexibility which we believe is a priority and invaluable in a dynamic environment and an environment of continuous change; and importantly, we marry against that significant capital flexibility with which to pursue that strategic flexibility for the benefit of those we serve and ultimately deliver ongoing differentiated value to our shareholders. And that brings me to the fifth and final point. We have a compelling, attractive outlook with 10% to 13% on average compounded EPS growth in our portfolio. And as I would note, we have a track record of delivering on targets we established, noting we delivered 15% EPS CAGR over the last decade. In addition to the 10% to 13% EPS CAGR, we have a meaningful dividend that approximates about a 2% yield above and beyond that 10% to 13%. And then we have a long-term, very attractive revenue growth outlook for our corporation and earnings growth outlook for our corporation of 6% to 8%, which is significant when you consider the breadth and depth of our portfolio. Taken all together, as you had a flavor today, our team is excited about the future and the opportunities in front of us because we're privileged to serve 175 million customer relationships around the world each and every day. And we focus on continuing to serve with differentiated value, but also growing those relationships, which for us means more lives to affect for the better, more resources, therefore, to invest in this process and then additional growth opportunity and ultimately sustain attractive shareholder value. We look forward to our ongoing conversations. And again, thank you for being with us today.