Services business in Evernorth. It's about 30% of the company that we expect low- to mid-single-digit type growth on an ongoing basis. So three large-scale platforms. You asked specifically about the commercial employer business that's in Cigna Healthcare, which again is our health plan business. We've had a long track record of success here, and part of it's the focus and the expertise that we've built up over time. But the opportunity we have going forward for disproportionately high growth is in the under-500 employer size segment, what we call the Select segment. So you can think of these employers who have between 50 and 500 employees. Today we have about 7% market share. That's up from it was 5% just five years ago.
So our share has been gradually building, and we see the opportunity for that to eventually get into the double digits from a share standpoint, which is where our over 500 market share is today in the commercial employer space. We see that as a significant opportunity going forward. The reason we've been successful in that space is both improved affordability at a local market level, but also a very consultative model that we've employed with employers from the standpoint of understanding how health benefits can be a weapon for them relative to talent attraction and retention, and the fact that we're agnostic to funding arrangements. So we've for a long time had ASO or self-funded arrangements in the down market segment, which some of our competitors have been reluctant to do because it's lower revenue, even though it's very attractive from a profitability standpoint.
That's the subsegment within commercial employer that we're most excited about growth going forward.
Yeah, I guess in Q1, when it looked at your commercial membership, the membership was down pretty much in every segment except for, I guess, the Select business. So what happened there? Why weren't we seeing better membership trends when the economy is doing relatively well? And then how should we think about the rest of the year?
Yeah, the Select segment I'll come back to the core of the question. The Select segment, you can think of as having more rolling renewal dates. So because these are smaller employers, it's not as concentrated on January 1st. So we tend to see intra-year growth in that subsegment specifically, so the under 500 Select segment. So we'll see throughout the year growth in terms of sequential lives in 2024. As it relates to your point on the larger segments, if you look at our middle markets and national accounts, we did have some self-funded fee-based clients that were lost for 1/1/2024. We knew about that because from the standpoint of the pricing environment, we didn't chase the pricing. So not material to our income, but they did create a dent to the lives on 1/1/2024. Now, that's on the heels of a couple of years of really strong growth.
If you go back and look at where we were at the end of 2021, our commercial employer book now is much bigger, 2 million-3 million lives bigger. So we've had a lot of growth, but in this specific time period, we had a couple of known employer losses, Kevin.
Does that mean that the market's getting more competitive in that marketplace, or is this just digesting recent growth?
Yeah, I wouldn't characterize it as more competitive in general because there were only two significant fee-based clients. So out of the hundreds that we serve in that space, I wouldn't necessarily conclude it's more competitive. We're broadly seeing rational pricing from our competitors, but here and there, you'll see a situation where the pricing is a bit aggressive.
And so as far as the rest of the year goes, you expect membership to kind of trend up from here as the year goes on? Is that?
We do. In the employer business, we expect there to be intra-year growth in the lives such that the full year commercial employer book, year end 2024 versus year end 2023, should be flat to potentially up a bit.
Okay. Then you guys are getting out of the Medicare Advantage business, and you don't have a Medicaid business. Can you just talk about your views on the government business? Why isn't that part of your portfolio strategy today? It seems like almost every company has a diversified portfolio. Aren't there benefits of having that?
There's a few different questions in there, so maybe I'll try to go deliberately through this to make sure the audience understands all the pieces in our thought process. So to your point, we're in the process of divesting our Medicare businesses as we speak to HCSC on track for an early 2025 closing date of that. We've completed the DOJ review process. We got through the federal antitrust review already, so a couple of key milestones have already been met. Again, on track to deliver that divestiture in the first quarter or early part of 2025. Stepping back, though, why would we divest the business? I think is more where you were going with the question. We continue to see the Medicare subsector of the U.S. healthcare space as an attractive part of the U.S. healthcare market.
So this was not a verdict about Medicare not being an attractive subsector. But for us, relative to where the Cigna Group is positioned, our strengths are existing assets and where we can create the most value. We concluded that given its relatively small size in our portfolio, the amount of human capital and financial investment that would be required to scale it to a level that's significant for our company was too tall of a task and that it was best in someone else's hands. So that's what led to the decision to divest the business. So this was not a verdict about the Medicare market. It was relative to the size of our company and the things that we're prioritizing and focusing on. So I talked about especially pharmacy earlier, our commercial employer business, and the strength in our pharmacy benefit services platforms.
Those are getting disproportionate investment resources, and we have a sustained right to win in each of them. Now, stepping back from that, our Evernorth Health Services business serves a lot of Medicare lives today. We serve a lot of Medicaid lives today, particularly with the win of Centene that has now gone effective January 1st into our book. So we now serve 20 million or so customers of Centene across Medicaid, Medicare, and across the entire Evernorth portfolio. About 30% of all the customers we serve there are government-sponsored Medicaid, Medicare, DOD. So between our pharmacy benefit services, specialty pharmacy, we serve a lot of Medicare, Medicaid, government lives, but through the services chassis as opposed to the health plan chassis. So in the long run, not having a health plan presence presents an opportunity for us strategically, something we could consider.
It's not necessarily in the near term where we're going to be focused, but it's an opportunity in the long term for us to consider.
Is that true for Medicaid as well as Medicare, or do you have a different view about those programs?
Well, similarly to Medicare, after the divestiture, we won't have any health plan presence in Cigna Healthcare. As we go through our strategic reviews of any decision that we make, we'll assess Medicare, Medicaid, and other lines where we're not active. I wouldn't say we have a stronger view of one versus the other in terms of the relative attractiveness. Ultimately, it'll come back to as we think about the criteria for where we invest or the criteria for M&A, each of the specific situations would need to be carefully reviewed. We have concluded that we don't intend to organically enter Medicaid or Medicare. So if we are in those lines in the health plan business, it would be through some sort of acquisition down the line.
All right. Can we talk a little bit about Evernorth then for a minute? You guys have kind of broken out that PBM business separately from the specialty business. Can you talk a little bit about the decision to do that and why you think that's important for investors to understand?
Sure. Yeah. So starting in the first quarter, we divided the Evernorth business into two operating segments or subsegments. And again, stepping back, Evernorth is the health services platform for Cigna. It's about 60% of our income. And then Cigna Healthcare is the health plan, about 40%. So the 60%, we divided into the two components. And part of this was we had a lot of questions coming in from investors to help us understand the pieces better. But also part of it is we wanted to make sure we really put a spotlight on the specialty and care services platform, which can you think of each of them as approximately equal today in terms of their contribution, 30% of the total company's income from both of those two operating segments?
But we found many people were taking our specialty pharmacy business and grouping it with the rest of our pharmacy benefit services business and just thinking of that as a prescription drug-oriented business. Yet the two have very different growth profiles going forward. So the specialty and care services business, $400 billion addressable market, it'll grow high single digits for the foreseeable future. And we're the leader in that space, and we've expected 8%-12% annual income growth out of that operating segment on a go-forward basis. And we've delivered that historically. However, we don't feel like everyone understands or appreciates the power of that business today because historically, when it was lumped together with the rest of Evernorth, it was easy to say that's a big PBM.
Yet the reality is the specialty pharmacy business is really a heavy-duty clinical care delivery model in a really attractive, highly growing addressable market. And so we wanted to put a spotlight on that for investors and allow you all to see the fact that that's going to be a very high growth business for the company. And ideally, think of it from a valuation standpoint differently than what the rest of Evernorth is, which is our pharmacy benefit services platform, which we expect to grow 2%-4% going forward. So it'll still grow and still has secular tailwinds, but not to the 8%-12% growth rate of the specialty and care services platform. So that's why we decided to go down that route, Kevin, with a lot of questions.
We wanted to put a spotlight on the high growth subsegment that we have within Evernorth.
I guess maybe to that point, I think since this was the first quarter where we could look at it, it just optically looked a little bit strange when the PBM business grew so much off the Centene contract, but the specialty business didn't seem to get the same lift. Can you talk about why specialty didn't get the same bump the PBM did?
Sure. Sure. Yeah. And you're right. We had the benefit of the Centene contract onboarding in the pharmacy benefit services operating segment. So if you look at the quarter-for-quarter growth, it's very high, in excess of 40% in the pharmacy benefit services platform. Now, the specialty and care services still grew 12% year-over-year, so nothing to sneeze at in that regard. But to your point, the Centene recognition, if you will, in terms of where the financials show up, is largely in the pharmacy benefit services platform. So we have our Accredo specialty pharmacy as one of the specialty pharmacy options for Centene customers, but it's not exclusive. It's one of the options. So to the extent that a Centene customer fills a script at our Accredo specialty pharmacy, we recognize it in that subsegment.
But the lion's share of the relationship is in the pharmacy benefit services platform today.
When you think about that 8%-12% growth algorithm, how should we think about it? What are the key drivers to that?
The most significant driver of that is the core secular growth in the specialty pharmacy market. What I mean by that is looking back over the past decade or so, much of the innovation in healthcare has been in medical devices. Now we're starting to see pharmaceutical innovation not even in the early innings. We're starting to get in the middle innings of pharmaceutical innovation over the next decade, really being the next wave of healthcare. The specialty pharmacy market in particular will see a lot of that. So whether it's gene therapies, Alzheimer's drugs, we're seeing right now the effect of GLP-1s starting to ramp, as you all know. Those are all examples of drug innovation that will drive high secular growth in that $400 billion specialty pharmacy market.
Our Accredo specialty pharmacy today, we have, depending on which measure you use, a 20% market share range, something along those lines. We have a scaled business in a high-growing subsector with a lot of clinical experts because these are high-cost drugs. Often, they require temperature control or they require specific administration in a person's house or in a physician's office. So these are high-cost drugs. This is not going down to your local drugstore and picking up a generic. They're complicated specialty drugs, and we're really well positioned. So that's the primary driver of the 8%-12% growth within there. The two others that I would highlight are we have a distribution business for specialty pharmacy as well called CuraScript. It's been growing double digits for many years.
We have an opportunity to see that grow at an even faster rate on a go-forward basis as more biosimilars are brought to market and more competition for high-cost branded drugs enters the market. So we've got an opportunity there. And then in our behavioral health business, we have an opportunity for outsized growth there as well. Today, that's a relatively small part of the company, but there's a tremendous amount of demand for mental health right now, both from our Cigna Healthcare customers, but also our external and affiliated clients that Evernorth serves. So all those things taken together lead to the 8%-12% expectation.
But that last one, so the first two were actually kind of specialty drug-driven. The last one, that's a medical management overlay, not a pharmaceutical.
Correct. Yeah. So from the standpoint of trying to keep things simple, only having two operating segments in Evernorth, the specialty and care services includes primarily specialty pharmaceutical, but we have some healthcare services in there as well, things like behavioral health, things like our MDLIVE virtual care, things like our eviCore medical benefits management.
It seems like everyone is talking about adding more of these services and these carve-out benefits. I mean, how would you characterize the competitive environment today for these types of things like behavioral?
It seems like, again, Elevance is doing it. United's been doing it. You're doing it. How do you win in that market?
I think to this point, it's important to subsegment the employer space a bit more. I think your question's probably geared to the employer market, if I heard you right there. So the under-500 market that I was referencing earlier, where we have outsized growth opportunity, what we call the Select segment within Cigna Healthcare, generally speaking, those employers are buying the full suite of solutions from us. They're not going through procurement for mental health separately from their medical benefits, separately from their prescription drug. They're generally buying the full suite of solutions from us. That's a function of generally small HR departments. They want simplicity as opposed to having to go through complicated procurements and having to manage multiple partners.
As you go up market into the over-500 space and then eventually up into the largest employers, there tends to be more of the à la carte or multi-partner procurements. And so that tends to be that's been the case for a long time. That's still the case. We're seeing a little bit of, we use the term point solution fatigue, where some of our largest clients—I'd spend a lot of time with them in my Cigna Healthcare role—have said, "I've over time invested in some of these smaller point solutions, and they're not really paying back the way that I thought they would. So I'm looking for a more integrated solution," which presents an opportunity for us and some of our large-scaled competitors to see some consolidation from the point solution vendors. But broadly speaking, down market, we have everything in.
If we sell to the client, up market, it's a bit more fragmented today with some opportunity for consolidation.
Okay. Can you talk a little bit about the PBM environment? You guys just won a large contract. Anything to highlight there as far as over the next year or two that anything you have up for reprocurement or any larger contracts that might be coming to market?
Yeah. The Centene contract, that was just effective 1/1/2024, far and away bigger than anything else that's in the kind of short to intermediate horizon for us. And for 2025, we'd expect, based on where we sit here in the middle of May, mid-90s% or better retention on our PBM book of business based on where things stand and a few opportunities for new business coming in as well. That's all factored into the forward-looking 2%-4% average annual growth algorithm for the pharmacy benefit services business, but not anything anywhere near as sizable in the 2025 cycle as what we had with Centene.
As far as the Centene contract, I guess last year was a drag. You prepared for it. This year, it's talking more break-even. Next year, you should be at target margins. Are you still on track for that dynamic?
We are on track for that dynamic. So we don't intend to every quarter talk about the financial performance of Centene. But that broad picture you just painted is consistent with our latest expectations. 2025, we should be at run-rate profitability on the contract. And the installation went great. So we still have regular dialogue with Centene. They've been pleased from everything we've heard in terms of the operational performance, which was not an easy thing to do, to bring 20 million new customers over into our environment. We're really pleased with the performance from the team.
All right. Great. Can you talk a little bit about just going back to the health plan business, the exchanges? You guys pulled back noticeably on the exchanges in a couple of states. Where are the margins today, and how do you view the exchanges going forward?
Sure. So the exchanges are within Cigna Healthcare for us. And you can think of it as this year, about a $4 billion book of business from a premium standpoint. So within Cigna Healthcare, that represents under 10% of the total. But it's an area we see growth opportunity on a go-forward basis. Now, we had to do some repositioning in 2024 because 2023, in two of our largest states, with the benefit of hindsight, we underpriced the business in two of those states. And so we went through a new product positioning as well as a repricing exercise in two of those states, which led to a reduction in membership year to date as we expected. So the good news for us is we've delivered 2024 where we needed to from the standpoint of fewer customers but more profitable.
As we went through the repricing that I made reference to, our 2024 expectations are that the book itself will run slightly below our target margins. Our target margins are 4%-6% on that business. We expect to be slightly below that. That's what's incorporated in our guidance. The first quarter and the April experience is consistent with that expectation.
Would you expect to be at target next year under the year of repricing?
Barring any unforeseen events, that will be our expectation.
I think you guys have a longer-term view that that business will grow. Was it 10-15?
Yes. So inherent in Cigna Healthcare, we expect average annual income growth of 7%-10%. Within that, we expect the individual exchanges to grow 10%-15%. So the weighted effect of 10%-15% versus the other components gets to 7%-10% at the total Cigna Healthcare level. Part of that for us is addressable market expansion since we're only in about a dozen states. So we have new states we can get into. Some of the existing geographies, our market share is lower, so there's opportunity there. And ultimately, that $4 billion of premium, we see growing in time. Now, the entire company, of course, isn't predicated on that business performing, but we see it as an important part of the healthcare system.
Is that the only part of your commercial business that was kind of under target? Are you generally speaking back to target margin and commercial outside of exchanges?
Yes. So Cigna Healthcare, if you think of the components, the U.S. employer business, essentially at target margins. The international health business, essentially at target margins. The individual exchange, a little bit below, as we just talked about. And then our Medicare business, which we're in the process of divesting, currently weighed down by SG&A. So it's below targets, although the medical care ratios are not out of line with where we would expect.
Okay. It's interesting. It feels to me like Cigna's in a pretty good spot right now. When I think about next year, there's not really any obvious headwinds that I can see to your business. So next year, you're going to have trends going to remain high. Unit costs seem to be driving commercial trend, and that's probably going to be high again next year. So that's good for revenue growth. You've got the Centene contract ramping up. Sounds like the RFP pipeline's going well on the PBM side. So it seems like everything's kind of going well in your favor. Is there anything we should be thinking about from a headwind perspective that is an offset or anything that keeps you up at night as far as next year's growth goes?
I hate to say there are no headwinds, but there are no known headwinds that are sizable that I would highlight. I broadly agree with the framing that you provided there. Actually, two months ago on our investor day, you all may have noticed we increased the ceiling of our EPS growth algorithm on a go-forward basis. It was 10%-13% for a long time. We increased it to 10%-14% because we see the next several years being opportunities for strong rates of growth despite it being a pretty disrupted environment that we're operating within.
So whether that's the forces you described or the drug innovation that I made reference to, all those things contribute to our businesses being really well positioned for the next few years and not a specific one, two, three headwinds that I would call out as we step into 2025. Of course, we always have to respect the fact that medical cost utilization could be higher than expectations. Of course, we're always going to be investing in operating expense or making investments in strategic capabilities that could weigh on operating expenses in any given time period. But broadly speaking, don't see any notable one-time headwinds.
Yeah. And then you talk a little bit about the share repo that you're doing this year. You guys are in the process of doing the first $5 billion. What's the appetite or ability to do it, to continue share repo in the back half of the year? And your debt to cap in Q1 was 44%. You guys usually talk about 40% as the target. How does that play into how you think about share repo and the timing?
Yeah. So we've continued to see our shares as a great use of our deployable capital, which is one of the reasons we've done so much share repurchase the last few years. And in 2024, we've committed to the majority of our discretionary cash flow going for share repurchase. We're on track to deliver against the commitment we made, which is at least $5 billion by the end of the first half of 2024, so at least $5 billion to share repurchase. So we initiated a $3.2 billion ASR in February that will complete by the end of this month. And then we'll do some open market repurchase to achieve that goal by the end of June. So we're fortunate to have the cash generation that allows us the flexibility to do this sort of repurchase.
As you think about the back half of the year, even after you remove CapEx and you remove shareholder dividends, there's still, call it, $3 billion or so of fungible cash that'll be available for deployment between either some debt repayment to the extent we delever a bit or to the extent we see a strategic M&A opportunity. So we see those buckets as a bit fungible in the back half of the year. But we continue to see share repurchase as a very attractive lever for the company. To your point on debt, we were a little bit elevated in the first quarter from the timing of our debt issuance, which was in part to fund the ASR. We also had a write-off of one of our assets that temporarily elevated the debt to cap. Over time, we're committed to a 40% debt to cap ratio.
That's what we've aligned with our rating agencies on. And so at times, we'll be above that. We were at 40 at the end of the year. So we'll delever down to that level at some point.
Yeah. And I guess when we think about you guys talk about 65% of your cash flow either going to M&A or share repo. And I appreciate viewing your own stock as attractive. We do too. But you think about M&A, one of the pushbacks that I have on Cigna's strategic capital deployment, it just seems like that there should be something out there that could kind of push the company forward. But since you bought Express Scripts, you've raised more money in asset sales than you've deployed on acquisitions. And so it feels like everyone around you is kind of more aggressive on deploying capital. So what are your thoughts about I don't want to say it's an arms race, but are you missing out on anything? Is there anything that you look at today and say, "Yeah, it would be better to have this or that"?
Yeah. We see M&A as an important part of our capital deployment strategy. So full stop. And even though, to your point, there haven't been as many high-dollar, high-profile acquisitions since we acquired Express Scripts, it's a constant area of review and focus for us strategically. So to your point, 60%-65% of our capital available for deployment, we see as fungible between M&A and repurchase. But we're not going to sit on cash either. So if there's not an attractive M&A prospect, we're going to use the repurchase lever because we view our stock as a very good investment with where we sit today. Now, strategic M&A for us falls into a few different categories. There's where can we improve our competitive position and our competitive advantage in our existing businesses? So I went through the different components of the company earlier.
Then there's where can we expand our addressable market, our reach, which could be in Cigna Healthcare. We talked about a few of the lines where we don't have a presence or we won't have a presence in the future. Or it could be in Evernorth where we have more opportunities for services, particularly health services. So those are examples of areas that we're constantly looking at. But importantly, every asset needs to be viewed individually. And we put it through the lens of, does it strategically push the company forward? Is it financially attractive, meaning accretive over time and meeting return on capital expectations? And can we get it done, both from the standpoint of having the right counterparty and getting through antitrust?
I guess I understand getting into new markets or getting to new geographies. But what does it mean to say to improve your competitive positioning? What does that mean?
Yeah. So in the three large-scale assets I made reference to, Cigna Healthcare, especially in care services and pharmacy benefit services, there are examples of ways where we can further extend our advantage into subsectors. So in Cigna Healthcare, we have certain geographies where we're less competitive. In the specialty and care services business, we're a little more nascent as it relates to serving health systems and hospitals. Those are examples of within already large-scale businesses where there could be an advantage to build.
All right. I think that's all we have time for. Thank you very much.
Thanks, Kevin. Appreciate the time.