The Cigna Group (CI) Earnings Call Transcript & Summary

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

Great. Thanks, A.J. Thanks for having us. And everyone, thanks for joining. I know we're at the -- sort of towards the tail end of the conference. So I appreciate you being here. I'm just going to say a couple of things before we jump in. So one, to start, we've been really pleased with our performance this year, especially coming out of the third quarter with strong performance. And then also being able to reaffirm our full year EPS guidance of at least $29.60 again coming out of this quarter. We've been operating in a very challenging and dynamic time. Despite that, we've been able to execute and also invest for the future. And so I'd point to 2 things there. One, our investment in Shield, so an investment in a company and in a space, the specialty space that's growing 17% to 19% on a big TAM. So really excited about that. We're also really excited about a couple of weeks ago, we announced the new transformative rebate-free model, and Adam and I are really excited to be here today to talk to you all about that and get into some more depth there. The last thing I'd say is just given where the stock is, we don't believe that the stock price reflects the true value of our long-term proposition and our ability to grow. And so as I think about capital deployment coming out of this year and into next year, I'm going to be really focused about being opportunistic on the stock repurchase side of things, while at the same time, using our capital in the appropriate ways, but also following our deleveraging plan. So excited to think about it a little bit differently given the opportunity in front of us. So that was all I wanted to say to start...

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

Sure, A.J. I'll take that. Good morning, everyone. So we're thrilled to be able to bring this new model to the industry. It's unlike anything that has been done in the pharmacy benefit space in decades. We're reimagining the pharmacy benefit. How we're going to do that? One is, yes, it's going to be a rebate-free model, which means for the consumer, an upfront discount where they immediately receive the full value of what we negotiate with the drug manufacturer. It's one big benefit. Another big benefit is we are going to be enhancing our system to where regardless of where the lowest price may exist. Normally, that's within the ecosystem of what we negotiate at Express Scripts, but it also could be a direct-to-consumer price that a manufacturer may offer or it could be within the cash pay market for a drug that may not be covered under the benefit. We're going to seamlessly be able to pull that lowest price. We're going to be able to have it still go through our ecosystem to apply all the safety and quality checks and we'll be able to immediately apply it to the patient's deductible. So for the consumer, there are some big benefits here. In addition, we're going to be able to reimburse pharmacies, the community pharmacies at their acquisition plus a dispense fee. So we're going to be able to help to solve the issue around community pharmacies in rural and urban areas from an access-to-care perspective. And we're going to do all of this with a simplified administrative fee that we are charging to our clients that will be delinked from the price of the drug. So very different from today, that will be delinked from that price. It will be a flat administrative fee to simplify the pharmacy model. Thus far, feedback, especially from President Trump administration, Secretary Kennedy administrator has been very positive as well as other members on Capitol Hill about us and our forward-thinking model here that's fully transparent and delivering real value to the consumers, but also being able to provide value to our clients. That is very different than a point-of-sale rebate model, which is retrospective, and there's reconciliation that occurs in those types of models and their estimates and the complexity within a point-of-sale model. This is an upfront direct discount that's going to be available to our -- to consumers while also keeping our clients' costs in check. So this model will be durable, sustainable and it future-proofs us and will be a competitive advantage for us for 2028 and beyond.

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

A.J., this model, we believe will be premium neutral for our clients compared to the existing model that exists. And it is important to point out, although we are going to be moving on our new standard will be this new model, we are still going to continue to support a rebate model for the foreseeable future. So we will continue to have those options. For this specific model, though, we will, one, be able to provide for the consumer dramatic value on these branded drugs. There are a lot of branded drugs today, which are not ever picked up because of the cost. By reducing that barrier, patients are able to access the medications, refill the medications on time, which will lower total cost of care, bringing cost down. Secondly, drug manufacturers today do try to offset many patients that are in the deductible or high coinsurance phase and they buy down the cost of those drugs at the pharmacy counter. We are now going to be able to effectively reduce the need for those types of programs. That creates another opportunity for us to extract value from pharmaceutical manufacturers and bring that back into the plans to help offset those premiums. Even with all those pieces, we will continue to be able to offer premium-neutral options to our clients to allow them to make those decisions.

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

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

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

Sure. So the timing is for 2027, we'll be moving to the rebate-free model for Cigna Healthcare's fully insured book. For 2028, this will be available to the rest of the Express Scripts book of business. So that's where we'll be contracting with manufacturers. So we have these next call it, 2 years, where we're going to be transitioning to this new way of contracting. We're going to be making those short-term investments to be able to build all the different pipes that we're going to need for this new type of model to have the good data analytics for the new type of contracting that we'll have. But remember also, we're going to continue to also have the core type of contracting around the value-based solutions that we have within our SafeGuardRx portfolio today, the other clinical services that we're able to contract with manufacturers on. So we expect this to be a complement to those within that portfolio while still supporting a rebate contracting model, too.

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

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

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

Yes, I can take that one. And maybe to bring it back up to what we said coming out of third quarter earnings. So we expect some pressure on the PBS line next year. Part of that pressure is the recontracting and the new client renewals and extensions that we're doing. And then part of it is the investments that we're going to make around this transformative rebate premodel. More than half of it is the first thing. So for the piece that's related to the investments we're going to be making, and I think it's really important to sort of come back to -- as Adam has talked about this in terms of transforming the market here, we are not just tweaking an existing model. We are doing something holistically different than what we've done before. And so just for context, right, 2,000 clients, 100 million lives in this space. And so we are building and investing in an infrastructure that's going to support that under a new model than what exists today. So as I think about what are the things in that category that we are going to be spending on. So probably technology is the largest, the first thing I'd mention. So all of our systems are designed to support a rebate model. We are going to have to invest in those over the next 2 years, so in '26 and '27 to be able to have the dual model in place. So that is one. The next 2 I'd sort of put in the same category is maybe a mix of 3 things. So process optimization, operations optimization and also all of the recontracting work. Adam talked about the manufacturers, but we also have to recontract with all of our clients throughout this process. So there'll be investments across those categories. And then finally, I'd say a big important step here is having the right data so we can optimize our model. So investing in data and analytics tools that help us find the right places to expand opportunities with clients, the right places to innovate. And so as we think about '26 and '27, you could think about roughly equal amounts of investment across those 2 years to stand up everything that I just described.

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

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

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

So we see this more as an opportunity than a risk and a competitive advantage for us of understanding where the puck is going in terms of the pharmacy benefit space, the unpredictability around rebates whether it's the Inflation Reduction Act or it's the most favored nation, like there are a lot of things changing right now in the drug pricing landscape, which is causing some challenges from a client perspective in terms of rebate predictability. This new model takes that and makes what clients are going to be paying much more predictable for them. It also simplifies it. So that's an opportunity of removing the complexity out of the pharmacy benefit space, how our pricing works, delinking pricing from the cost of the drug. That type of opportunity is going to be very attractive to our clients to where I think if we're sitting here in 2 years and we hadn't built this model, you'd be asking me why didn't we see this coming and why weren't we more prepared to have something new like this. So I see this as a real opportunity for us to have something very attractive for our clients that will be available to them over the next 2 years. And at the same time, for those clients that want to stay on an existing type of model and want to continue to have their rebates, we're going to continue to make that available to them as well. So I don't see this again as a risk. I see this as a real opportunity for us, not only to continue to have strong retention of our current clients, but also from a new sales perspective of having something new and different that's out in the market and available to clients. And keep in mind, the core components that we're going to continue to deliver to our clients, those pieces don't change in terms of adjudication of claims, the clinical services that we provide, formulary development, those pieces will continue to be there, and we're going to continue to invest in those as well for both models that we'll continue to support.

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

Yes. So you can think about the PMPM fee. Let's think about fees in 2 categories. The PMPM fee is one category, and then there'll be fees for other services. So let me first talk about the first category. So the PMPM fee will not be a risk fee. That will be the fee that we charge clients for the services we provide. So drug price negotiation, the clinical and safety services, the administration adjudication of the plan. So those fees will not be risk-based, and they'll be based on -- and negotiated with the client and based on volume. The second category of fee will be around innovative programs like Adam mentioned earlier, Safeguard Rx, we have Enreach. Those programs allow us to take risk positions or risk against our fees. And we're very excited about the prospect of expansion of those types of programs and the opportunity that, that provides us. But in short answer to your question, PMPM fee is not at risk. We will have a risk component to the fee structure, but that will be in the context of innovative products that bring clients to us and enhance the services that they have and also enhance affordability and client experience or patient experience, I should say.

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

A.J., our ability to continue to meet our clients' contractual obligations on rebate guarantees has been manageable. We expect to continue to be manageable and to be able to meet those obligations. As I mentioned before, the unpredictability, though, of rebates and what's happening in the market today around changes like the Inflation Reduction Act is causing some friction in the market where we're working through those things with clients. We do have the ability with the vast majority of our clients to be able to adjust those guarantees when different market factors may occur or government intervention may occur. So we've been able to work through those amicably with our clients to be able to make those adjustments. So we would expect this to continue to be manageable. But it does speak to the challenges that exist in the market and why a new model makes sense and why moving to something that is rebate-free will make more sense, especially as you continue to see more of this disruption to continue to happen in the market where pricing is changing more today than we've ever seen it in terms of the different list price movement that we've been historically.

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

So the large client renewals whether that -- we've talked about Centene, Prime Therapeutics or the strong relationships that we've had with those clients and now we're -- the ongoing relationship that we're going to have. So we're thrilled to be able to extend those relationships for -- through at least the end of the decade. Those are all unique contracts because they are unique clients to us, and they're already in very transparent models, fee-based per claim type of models today. We will certainly offer to them the option if they would want to move to a rebate-free model. So they'll have that available to them. But being nontraditional clients already, they already have fully transparent models that we work very closely with them on. And we're proud of the work that we've been able to do to service them, not only through today, but also for quite a few years to come. Right.

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

Sure. Yes. So maybe for context, so the 3 large clients, you hit them all, DoD, Centene, Prime, altogether $90 billion worth of revenues associated with just those 3 clients and substantial volumes. Some of the clients were up for regular renewal and others were accelerated discussions. And so why we thought it was important to do that to accelerate. Obviously, we've got to go through the normal renewal process when it's appropriate. But for the acceleration, we really wanted to lock in through the end of the decade. And why that's important is we've talked a lot about the new rebate-free model. Having sort of that $90 billion of revenues, those clients and the volumes that come along with those, give us stability heading into the end of the decade and allow us to transition to the new model without fear of disruption in that space or distraction. So we feel really great about the relationships, as Adam described, and very good about the fact that we've got them locked in and we can focus on executing on in the new model in the most powerful way possible.

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

Yes, sure. So correct, A.J. What we've said about next year is we expect some pressure due to these accelerations and renegotiations, and that's a bit more than half of the pressure. And so as we think about the future, those fees are -- those contracts are fee-based. We would -- there are some increases in fees over the period of time, but it's going to look different than it did in the past in terms of low earnings and jumps later on in the contracts. And I think Brian talked about this during the earnings call, sort of stable margins for the future for these 3 big clients. Where we see the opportunity and Centene is a great example, is in terms of what we are doing for those clients and the opportunity to expand our relationships with them. So there's opportunity, in particular, in the specialty space with some of those clients to do more for them. And the better our relationships, the stronger the relationships, the better opportunities we have on the back end of that. So I'd see more of the opportunity coming from the expansion of the relationships on the margin side. I think you can think about margin holistically across Evernorth, right, our target is in the 3.5% to 4.5% range outside of the large clients getting back to those target margins over time.

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

So the more recent announcement that they made with the administration, certainly, we're working -- we're engaged with both manufacturers. It's early as we're working through what those changes potentially could mean in working with Novo and Lilly. I think on its Phase 1, this looks like it's certainly a win for consumers and hopefully for our clients as well in lowering the cost of these medications, improving access to these medications. And as I mentioned earlier, our ability to continue to build out functionality, we'll be able to connect with any type of direct-to-consumer offering. It also provides us with an ability to continue to negotiate to bring down those net costs overall. So although it's early, I would expect this, one, to be manageable; two, to be neutral to us as we continue to work through and to expand access in these drugs. And as they continue to expand the number of indications that are available and us to continue to work to make sure that we can provide affordable access to the patients that need these drugs most.

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

Sure. So not too different from what we said coming out of third quarter earnings. So just as a reminder, last year, we had an MCR in the low 90s in the business, a bit of a surprise in terms of how it evolved over 2024. So coming into this year, we've got a higher estimate than we did last year in terms of the overall MCR. We've been tracking against our expectations pretty much all year long. We are doing additional things this year. The standard things like looking at sort of paid ratios, everything is sort of in line with where we'd expect it to be. The other things that we're doing outside of what we've done before is really in the analytics space. So we have developed analytics that is able to look at each individual in the book, where they are against their attachment point, and to assess what our best estimate of how things are going to progress through the rest of the year, which is only a couple of months now. All of that is progressing where we would expect it to be. Specific to the pricing question, pricing is going as we expected it to go, meaning we are pricing higher than we priced last year. Our persistency is about where we'd expect it to be. 2/3 of the book reprices on January 1. So we're in that process right now, but it's going well. And we would still expect to recapture the portion of our margin recapture. And when we talked about it last year, we said over '26 in '27. We still see that as the path. So part of it will be '26 and the rest will be in '27.

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

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

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

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

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

Yes. If I think about the dynamics in terms of our cash flow trajectory, like you referenced being back half weighted. If you look at the past couple of years, it has been back half weighted. We had the benefit of the Medicare sale, which allowed us to do some repurchasing earlier in the year and in the back half of the previous year in anticipation. And so we've got that dynamic plus the other dynamic of -- we did the Shields transaction. Our leverage coming out of the third quarter was at 44.9% debt to cap. We want to get to a roughly 40% range, not exactly, but approximately. And so we're working on delevering at the same time that we want to execute on other elements of the capital plan, one being repurchasing. So I would expect that we're going to be opportunistic and that there will be maybe some pressure to that additional 4% to 5% as it relates to repurchases only.

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

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

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

Yes. I would make one, which is typically in a lot of the conversations we've had with investors over the last few years, I get the question of what about government intervention? And we didn't talk about that today. And I haven't talked about that really with many investors since we've launched the new model. And I think the reason why is we've been heavily engaged with the President's administration, heavily engaged with members of Congress. And so as we've rolled out this new rebate-free model, it addresses many of the issues and challenges that exist of what we consider from a regulatory overhang. We're addressing those things with the new model. And we're not doing it because of those things. We're doing it because it's right for the business. But I think it does speak to a new era for us as we introduce this new model and a new opportunity and why it's good for our clients. It's good for consumers, but it's also going to be good for us as well in addressing those challenges that exist in the market today.

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

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

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

Thank you, A.J..