Ladies and gentlemen, thank you for standing by for Cigna's Q3 2022 results review. At this time, all callers are in a listen-only mode. We will conduct a question and answer session later during the conference and review procedures on how to enter queue to ask questions at that time. If you should require assistance during the call, please press star zero on your touchtone phone. As a reminder, ladies and gentlemen, this conference, including the Q&A session, is being recorded. We'll begin by turning the conference over to Mr. Ralph Giacobbe. Please go ahead, Mr. Giacobbe.
Great, thanks. Good morning, everyone, and thank you for joining today's call. I'm Ralph Giacobbe, Senior Vice President of Investor Relations. With me on the line this morning are David Cordani, Cigna's Chairman and Chief Executive Officer, and Brian Evanko, Cigna's Chief Financial Officer. In our remarks today, David and Brian will cover a number of topics, including Cigna's Q3 2022 financial results, as well as an update on our financial outlook for 2022. As noted in our Earnings Release, when describing our financial results, Cigna uses certain financial measures, adjusted income from operations and adjusted revenues, which are not determined in accordance with accounting principles generally accepted in the U.S. , otherwise known as GAAP.
A reconciliation of these measures to the most directly comparable GAAP measures, shareholders' net income and total revenues, respectively, is contained in today's Earnings Release, which is posted in the investor relations section of cigna.com. We use the term labeled adjusted income from operations and adjusted earnings per share on the same basis as our principal measures of financial performance. In our remarks today, we will be making some forward-looking statements, including statements regarding our outlook for 2022 and future performance. These statements are subject to risks and uncertainties that could cause actual results to differ materially from our current expectations. A description of these risks and uncertainties is contained in the cautionary note to today's Earnings Release and in our most recent report filed with the SEC. Before turning the call over to David, I will cover a few items pertaining to our financial results and disclosures.
Regarding our results, in the Q3, we recorded after-tax special item charges of $23 million or $0.07 Per share for integration and transaction-related costs. We also recorded an after-tax special item benefit of $1.4 billion or $4.52 per share associated with the sale of our international life, accident, and supplemental businesses to Chubb. As described in today's Earnings Release, special items are excluded from adjusted income from operations and adjusted revenues in our discussion of financial results. Additionally, please note that when we make prospective comments regarding financial performance, including our full year 2022 outlook, we will do so on a basis that includes the potential impact of future share purchases and anticipated 2022 dividends. With that, I'll turn the call over to David.
Thanks, Ralph. Good morning, everyone, and thank you for joining today's call. Our team is performing well in a dynamic environment, and we delivered another strong quarter of revenue, earnings, and cash flows. Today, I'm going to spend a few minutes highlighting key drivers of our results in the Q3 and why we are once again raising our 2022 full year outlook for adjusted earnings per share, as well as for growth in medical customers and enterprise revenues. Then I'll address how we continue to expand and enhance our capabilities for the evolving market needs, and I'll also provide some initial perspective relative to 2023. Brian will share more details about our Q3 results and our outlook for the rest of the year. Then we'll take your questions. With that, let's get started.
During the Q3, we delivered results that were better than our expectations, including total revenues of $45.3 billion and adjusted earnings per share of $6.04. We continued building out our momentum this year, and we are confident we will deliver on our increased full year 2022 adjusted EPS guidance of at least $23.10. We also expect to continue advancing our capital deployment strategy, including investing in our business to drive innovation and growth and repurchasing at least $7 billion of our shares this year, all while paying a meaningful dividend. Our performance in the quarter reinforces the impact of our sustained commitment to service and innovation, our progress in retaining clients and expanding relationships with additional services, as well as winning new business.
Evernorth, our health service platform, performed well again, with solid top line and bottom line results, driven by our market-leading innovation and affordability across our pharmacy benefit services, specialty pharmacy, and Evernorth Care Group. Cigna Healthcare, our benefits portfolio, also was key to continuing our momentum in the quarter. Our U.S. commercial business is having a very good year with solid client retention levels and new business wins, particularly in the middle market and select segments, leading us to once again raise our full year outlook for medical customers. Our medical care ratio for Cigna Healthcare was better than expectations at 80.8% in the Q3, demonstrating the effectiveness of our affordability initiatives and targeted pricing actions. Overall, we're very pleased with our Q3 results. Now I'll take a few minutes to walk through how we are well-positioned going forward with Evernorth and Cigna Healthcare.
Within both platforms, we have differentiated businesses and a clear, durable three-part growth framework. First, through our foundational businesses, including our pharmacy benefit services, U.S. commercial, and international health businesses. With these mature scale businesses, we establish core relationships with corporate clients, health plans, and governmental entities. Our capital efficient operating models will further support steady growth as well as strategic and financial flexibility for our company. As we look ahead for these businesses in 2023, in our pharmacy benefit services, we're expecting another year of high client retention levels complemented with new business wins. We're also very pleased with our solid start to the selling season for 2024, including our new multi-year agreement for Express Scripts to be the pharmacy benefits and specialty services provider for Centene.
Working with Centene, we will make prescription drugs more affordable and accessible for approximately 20 million Centene members. The strategic collaboration with Centene builds on Express Scripts' track record as a partner of choice and will present growth opportunities to provide additional Evernorth health services over time. We continue showing how we have a unique ability to partner across the healthcare landscape, expanding our reach and impact to more customers and patients. With this new health plan relationship, we are building on our previous collaborations such as Prime Therapeutics, Oscar, and Kaiser Permanente. For U.S. commercial, we are driving strong customer growth with wins throughout 2022, enabled by our consultative sales approach and our affordability gains, enhancing more competitiveness in more geographies, all while maintaining ongoing pricing discipline.
The sales and net growth in our national account segment are solid and outpaced prior results, and we are confident this momentum carries into 2023. In international health, we are sharpening our healthcare focus for targeted growth opportunities in serving individuals, employers seeking healthy and productive employees, and governmental entities that value our care management programs. We have momentum this year in customer growth, revenue and earnings and expect to sustain these results and performance throughout 2023. The second way we drive growth is through our accelerate businesses, which include Accredo Specialty Pharmacy, Evernorth Care Group, and our U.S. Government Business. These businesses have outsized opportunities to grow with compelling secular tailwinds as well as differentiated capabilities that benefit our clients and customers.
Looking forward to our accelerate businesses, we continue to be excited about the value creation opportunities in specialty pharmaceuticals, including biosimilars over the next several years. With our leading capabilities and expertise, we expanded our relationship to be the exclusive specialty pharmacy provider for the Department of Defense starting in 2023. This is further reinforcement to how we fuel sustained long-term growth in Evernorth by improving clinical quality for the benefit of patients and achieving significant savings for our clients. In Evernorth Care Group, we are advancing our care management and delivery strategies. One area of focus is enhancing virtual care that strengthens relationships between patients and their physicians to better anticipate health issues and intervene earlier. For example, with MDLIVE, we're providing better experiences and improved affordability with personalized care that is more convenient and effective in directing patients to the most appropriate care settings.
When in-person care is needed, MDLIVE successfully guides patients to urgent care facilities or other alternative sites of care, decreasing avoidable emergency room visits by at least 10%. We intend to further build on this progress by enhancing our virtual primary care offerings for patients with chronic conditions by providing continuous engagement with their physician, remote monitoring with connected devices, and real-time interventions between appointments. In U.S. government, we are continuing to make investments, positioning us to grow in 2023 and beyond. We are strengthening this business by building on our high quality, affordable Medicare Advantage benefits we offer with geographic and network expansion, as well as further product enhancements. Finally, a third way we drive growth is through our cross-enterprise leverage.
Here we harness capabilities across our company to accelerate innovation and have a greater impact than any individual could have on its own. Our opportunities here are driven in part by our rich longitudinal data and information we have to accelerate the development of new, more effective solutions for our clients and customers. Our Pathwell programs are a good example. With Pathwell Specialty, we're working across the medical and pharmacy benefits to reduce the cost of specialty infusions and injectables. In our Pathwell Bone & Joint program, we harness Evernorth digital navigation and advanced predictive analytical capabilities to reduce unnecessary musculoskeletal surgeries and provide better coordinated care. There is a significant addressable market for these programs as 50% of adults suffer from bone, joint, and muscle conditions, and these are major drivers to U.S. healthcare costs.
Additionally, we continue to take an enterprise view of our client relationships and successfully broaden and deepen them with our overall suite of capabilities. This has supported a number of attractive wins, and a good example is a very large new fee-based relationship for 2023 in our U.S. commercial team that has secured this offering by bringing a solution to a long-standing Express Scripts client. With our Evernorth and Cigna Healthcare platforms and our growth framework, we anticipate driving another year of earnings, customer, and revenue growth in 2023. We will provide detailed guidance as we always do on our Q4 Earnings Call. Having said that, I'll provide a view of some of the tailwinds and headwinds we see for 2023, which are largely consistent with the points we highlighted at our Investor Day in June.
With a strong selling season, we anticipate a tailwind of continued growth across both our Evernorth and Cigna Healthcare platforms. We expect additional margin improvement in Cigna Healthcare and with our leading position in the rapidly growing specialty pharmaceuticals market, we'll begin capturing value from biosimilars. Relative to anticipated headwinds, we will make meaningful strategic investments in our accelerated growth businesses. We will have additional costs as well as we prepare to support renewed and expanded relationships with the Department of Defense and Prime Therapeutics. A new development since Investor Day is our exciting strategic win with Centene, which will create a one-year headwind as we onboard this new partner. Putting all that together, we anticipate that these tailwinds and headwinds will largely balance themselves off next year, with the exception of our Centene headwind, which represents incremental cost for us in 2023. Now I'll briefly summarize.
Overall, our strong performance in the quarter and throughout the year shows how we are addressing the most pressing needs of our customers and clients and growing our business. We're investing in innovation to enhance our capabilities for future growth and continue delivering for all of our stakeholders. We're confident we remain on track for our full year 2022 commitments, including our increased adjusted EPS guidance for this year of at least $23.10. With that, I'll turn the call over to Brian.
Thank you, David, and good morning, everyone. Today, I'll review key aspects of Cigna's Q3 2022 results, and I'll discuss our updated outlook for the full year. We're proud of another strong quarter and are pleased to drive continued momentum from the first half of 2022, with Q3 adjusted earnings per share exceeding our expectations. With that, we are again increasing our full year adjusted 2022 earnings outlook to at least $23.10 per share, representing growth of 13% off our reported full year 2021 adjusted EPS. Looking at the quarter specifically, key consolidated financial highlights include total revenues of $45.3 billion, after-tax adjusted earnings of $1.9 billion, and adjusted earnings per share of $6.04. Regarding our segments, I'll first comment on Evernorth.
We are pleased with the continued profitable growth in Evernorth as our client-centric approach, deep pharmacy expertise, and strong track record of service continues to resonate with new and existing clients. One good example of this is our recently announced partnership with Centene that will deliver greater prescription drug affordability and access for their approximately 20 million customers starting in January 2024. This mutually beneficial partnership will bring significant revenue and will be financially accretive over the course of the multiyear contract term. Turning to Q3 results for Evernorth. Revenues grew 6% over Q3 2021 to $35.7 billion, and pre-tax adjusted earnings were $1.6 billion.
Evernorth's results in the quarter were driven by continued expansion of our accelerated growth businesses, led by our specialty pharmacy, as well as our focus on affordability and delivering lowest net cost solutions for our clients and customers. We also continue to make meaningful strategic investments to both sustain and create new sources of differentiation. These include investments which serve to deepen our client relationships and expand our services portfolio and digital capabilities. Overall, Evernorth delivered another quarter of strong results consistent with our expectations. Turning to Cigna Healthcare. Our 2021 results presented an opportunity to expand future margins, and our team has executed extremely well and achieved both strong membership growth and improved profitability here in 2022.
Q3 2022 performance continued this pattern as adjusted revenues were $11.2 billion, pre-tax adjusted earnings were $1.1 billion, and the medical care ratio was 80.8%. Our medical care ratio was better than expectations and continues to demonstrate the impact of our affordability initiatives and pricing discipline. The favorable medical costs in the quarter were partially offset by lower net investment income. Turning to medical customers. We ended the quarter with 18 million total medical customers, growth of 873,000 customers or 5% year to date. We continue to drive strong customer and client growth in our U.S. commercial and international health businesses. Overall, Cigna Healthcare results reflect continued execution against our commitment to increasing both customer relationships and profit margins in 2022.
For corporate and other operations, the Q3 2022 pre-tax adjusted loss was $299 million. As a reminder, this segment previously included earnings contributions from the international life, accident, and supplemental benefits businesses that we divested to Chubb on 1 July 2022. Overall, we delivered strong Q3 financial results that exceeded our expectations, continuing our momentum with contributions across our foundational and accelerated growth businesses. Now turning to our outlook for full year 2022. We have positioned the enterprise for continued strong performance in these dynamic times, as demonstrated by our strong year-to-date results and heightened reinvestment into our business. With that said, we remain mindful of the current economic backdrop and utilization environment heading into the upcoming winter months.
In light of these moving pieces, we are increasing our outlook for full year adjusted revenue and adjusted earnings per share. We now expect full year 2022 consolidated adjusted revenues of at least $179 billion, enabled by continued growth and deepening of customer and client relationships in both Evernorth and Cigna Healthcare. We are also raising our adjusted earnings per share guidance to at least $23.10 per share, representing growth of 13% over reported full year 2021 adjusted EPS. In Cigna Healthcare, we expect to continue to grow customers while expanding margins over 2021. We are improving our expected 2022 medical care ratio outlook to 81.5%-82.2%.
We are raising our expected full year 2022 adjusted earnings to approximately $4.05 billion, and we are raising our medical customer growth expectation to approximately 900,000 customers, which reflects strong new business growth and attractive retention levels in our U.S. commercial and international health businesses. Our full year 2022 enterprise SG&A ratio is now expected to be approximately 7.3%, an increase compared to our prior guidance as we further accelerate investments into our business. Now moving to our 2022 capital management position and outlook. Year to date through 3 November 2022, we expect to have repurchased approximately 22 million shares of common stock for $5.8 billion, including the accelerated share repurchase agreements announced in June.
We also continue to expect to deploy at least $7 billion to share repurchases for the full year 2022. During the Q3, we delivered strong cash flow from operations of $3.3 billion. We remain on track for another strong year of cash generation, providing us the fuel and flexibility for ongoing capital deployment opportunities. Our balance sheet and cash flow outlook remains strong, benefiting from our asset-light framework that drives strategic flexibility, solid margins, and attractive returns on capital. Now to recap, results in the Q3 were above expectations, reflecting strong growth across our diversified portfolio.
Evernorth continues to deliver attractive results, while Cigna Healthcare continues to grow and expand both customer relationships and margins, giving us confidence we will deliver on our increased 2022 adjusted EPS guidance of at least $23.10 per share. We remain well-positioned and expect another year of customer revenue and earnings growth in 2023. Relative to 2023, we deem the current consensus EPS to be reasonable when excluding the Centene contract win. Although consistent with our historical approach, our initial guidance would have likely started more prudently. As David mentioned, Centene implementation-related costs introduce a net new headwind for our 2023 financials.
That said, we expect a two-year compounded EPS growth rate from 2022 to 2024 to be within our long-term average 10%-13% annual range, driven by the strong earnings contribution from our broad portfolio, as well as 2024 contributions from the Centene contract win following the implementation cost impact that we will incur in 2023. We look forward to providing you with more detailed 2023 guidance during our Q4 call. With that, we'll turn it over to the operator for the Q&A portion of the call.
Ladies and gentlemen, at this time, if you do have a question, please press star one on your touchtone phone. If someone asks your question ahead of you can remove yourself from the queue by pressing star two. Also, if you're using a speakerphone, please pick up your handset before pressing the buttons. One moment please for the first question. Our first question comes from Mr. Stephen Baxter with Wells Fargo. You may ask your question.
Yeah, hi. Thanks for the question. Just wanted to ask, you know, congratulations on the Centene contract win. Wanted to ask specifically, you know, is it too early to have a view on what you're expecting the implementation cost to be in 2023? It sounds like you're kind of suggesting that we should potentially add that back to 2023 to kinda create a jump-off point. Is it too early to think that 2024 will see the contract there be financially accretive? Basically, how should we be thinking about that? Is 2024 too early to think about accretion? Thank you.
Morning, Steven. It's Brian. Appreciate the question very much. Maybe I'll give you a little bit of a flavor for the multiyear view here. I'd be remiss if I didn't start by saying this is a huge win for the organization and a great validation of the value proposition in the Evernorth segment of our company, and in particular, the Express Scripts team, which did a great job partnering with our new client here. We'll be laser focused on successfully implementing the new client over the course of the next 14 months to ensure smooth execution of their 20 million customers.
As I mentioned, over the lifetime of the contract, the relationship will be accretive to our financials, but you should think of the profit margin percentage being below the book average, as is typical for a contract of this size and scale. In terms of the year-by-year pattern and how to think about that, you should think of 2023 being a headwind, as both David and I said. Due to the implementation-related costs that are incurred prior to any revenue being received. We're currently sizing that at about $200 million for the 2023 year. Given we're only a week or so into the contract award, we still have a lot of detailed planning to do to refine that.
That's our current best estimate for what 2023 implementation-related costs will look like. For 2024, we are currently expecting to be in a neutral to small positive contribution standpoint in terms of the income. You can think of that 2023 headwind essentially unwinding in the 2024 financials. For 2025 and the subsequent years, we would expect to be at approximately run rate contribution levels on the relationship.
Thank you, Mr. Baxter. Our next question comes from Mr. A.J. Rice with Credit Suisse. You may ask your question.
Hi, everybody. Maybe just to ask, I know last year or coming into 2022, you made the comment that you wouldn't be doing any larger deals, and I think you defined that as anything north of $10 billion in acquisitions. I wonder, as you think about 2023 now, a lot's changed over the course of the year. You've been very active on the share repurchase front. What is your current thinking about whether you'd be open to transactions? Any comment about priorities or the pipeline and what that looks like? The flip side, of course, is your ongoing share repurchase activity. When you're giving these 2023 comments, do you have any sense of where you might size share repurchase activity in all of that?
Good morning, A.J., it's David Cordani. Let me provide a couple landing points there. First, stepping back relative to our capital priorities. Our capital priorities remain consistent, which is first and foremost to make sure the ongoing growth of the underlying business continues to be funded properly from a capital standpoint as well as from investments in innovation. Second, to obviously service our very attractive dividend. Third, we selectively pursue strategically attractive and financially attractive M&A and/or return excess capital to our shareholders through share repurchase. Specific to M&A priorities, as we discussed at our Investor Day, you can think about our M&A priorities largely focused on our Evernorth business and within the Evernorth businesses, a bit more pinpointed within Evernorth Care and our U.S. government business.
We may do tuck-ons, tuck-ins in other aspects of our portfolio that are highly financially attractive, but the strategic accelerants would be more in the accelerate business. To your question relative to earlier this calendar year, we deemed 2022 to be a bit unique for ourselves in that as we stepped into fiscal year 2022, we had the strong operating cash flow that Brian articulated earlier, as well as the anticipated inflow from the divestiture of a portion of our international business to Chubb. Those two numbers created well in excess of $10 billion that we had to steward forward.
That, coupled with our view of the price of our equity at that point in time, led us to create as much clarity as possible for our shareholders in 2022 relative to our commitment to share repurchase that we're on track for. Looking forward, we'll maintain the capital discipline. We will be open to strategic M&A that advances us in the accelerate businesses. Then a final note, you asked relative to 2023. As you have in the past, just think about we will deploy capital in the way I talked about before, either in a shareholder accretive way to achieve through the shareholder share repurchase and/or through accretive M&A. Our contribution to our EPS growth rate in the you know 3%-5% range year in, year out from the successful capital deployment remains intact.
Okay, great. Thanks a lot.
Thank you, Mr. Rice. Our next question comes from Mr. Justin Lake with Wolfe Research. You may ask your question.
Thanks. Good morning. Just a couple number questions. First, the accelerated growth in your stop-loss revenue has been impressive this year. Just wanted to get some color on what's driving that, and do you think it continues at, you know, we'll call it, you know, a solid double-digit pace into 2023? Then quickly, your medical cost reserves were down about 5% in the quarter. Just curious if there was anything driving that. Thanks.
Morning, Justin, it's Brian. On the stop-loss, yeah, we're really pleased with the strong growth that we've shown this year, as you can see, both in terms of the quarter-over-quarter and the year-over-year premium growth with 13% and 12% growth respectively on that. Important to keep in mind, there's a few components that drive that. One is we've shown a very strong growth in our fee-based Cigna Healthcare customers this year, and many of those bring with them stop-loss contracts. There's some additional units, if you will, of stop-loss that are embedded in the year-over-year growth rate. On top of that, we have had strong firm price increases on our existing client base.
As you noted, now in the double-digit level with the 13% quarter over quarter representing some of the later 2022 renewal dates, seeing strong price increases. We have seen a bit of increased penetration in our existing ASO clients as well of the stop-loss product. A few different factors that drove that strong growth. As we talked about in prior calls, we still have some margin expansion opportunity in our stop-loss book of business as we head into 2023. We would expect another year of strong growth in premiums for the stop-loss product in the 2023 calendar year.
On the reserve side, there's really nothing in particular I'd call to your attention there. We continue to employ a consistent methodology to establishing our reserves. There will be some natural variability just between product mix shift and inventory levels changing from quarter to quarter. Overall, we feel good about the appropriateness of our reserves. If you look year-over-year at the reserve levels, they all the key metrics that we evaluate seem appropriate and prudent.
Thank you, Mr. Lake. Our next question comes from Mr. Kevin Fischbeck with Bank of America. You may ask your question.
Great, thanks. Give you just a quick fact question and then jump into the other question. Can you help us size the revenue? It gets a little bit of difference in how Centene talks about the revenue contribution versus what it looks like, CVS was booking from a revenue perspective. Can you help us size from a revenue perspective with the Centene contract and whether you get all of that in 2024, whether that ramps up?
We'll do it.
I guess, like, my main question is just gonna be about maybe going back to that M&A point. I just find it very interesting that you've got some competitors who are just out there constantly buying things and adding capabilities, and other companies, you know, focusing more on share repurchase and selective smaller acquisitions. I guess, do you not see this as an arms race? It almost feels to me like a lot of companies are out there building capabilities. Do you feel when you think about M&A that potentially, you know, not pursuing M&A will be a disadvantage over the next, you know, three to five years if you're not doing deals today? Thanks.
Morning, Kevin, it's David. On your first piece, again, we'll look forward to providing you a lot more detail as we get into 2023 relative to 2024. At a macro level, I think there's two data points to think about relative to the size of the relationship. At today's state, there's about $40 billion relative to spend capacity, and as I noted in my prepared remarks, approximately 20 million customer relationships. That will evolve and change over time. As we provide more detailed guidance going forward, we'll try to separate that versus the revenue contribution. To your strategic question relative to M&A, first and foremost, I think your framing is quite important. I wouldn't call it an arms race. I would call it stepping back.
The marketplace demand for further value creation is and will remain consistently aggressive from that standpoint. Hence innovation, additional value creation, strong operating execution, and then selectively expanding your addressable market, depending on the strategy we deem to be mission critical. Two, now stepping back to ourselves, as we discussed in Investor Day, we're positioned with strong performing foundational businesses and well-positioned accelerate business. Those accelerate businesses are in sectors that have secular tailwinds. Then to the core of your point, how do we fuel additional capability growth? I'd ask you to think about it in a multi-pronged approach as opposed to M&A yes or no. One is significant targeted ongoing organic investment back into ourselves with new innovations, and some of which I talked about today, some of which we profiled at our Investor Day.
Our new Pathwell programs, our unique longitudinal programs, that take into consideration data, navigation support, best-in-class clinical engagement with physicians, and will increase value by taking costs out of the system through improving clinical quality. Organic investments are number one. Two is smartly and successfully leveraging our ventures capabilities to partner up with organizations to accelerate innovation. The third is M&A. We remain quite open to M&A. We do not deem it to be a silver bullet. It's a part of the growth support strategy. Organic execution, investments in organic innovation, smart leverage of our ventures capabilities, as well as M&A over time, and I would just come back and anchor it.
Hence, our track record of strong top-line growth and strong bottom-line growth with tremendous cash flow generation over the last decade by playing that recipe through which we will on a go-forward basis.
Great. Thanks.
Thank you, Mr. Fischbeck. Our next question comes from Miss Lisa Gill with J.P. Morgan. You may ask your question.
Thanks. Thanks for taking my question. I just really wanted to better understand as we think about, you know, the comment on the tailwind for 2023 around biosimilars. As you think about the plan design for 2023, are you seeing employers and health plans willing to put the biosimilars on the formulary? I mean, how much color and visibility do you have to that tailwind for 2023? And is that primarily Humira, or are we thinking about other biosimilars as well?
Good morning, Lisa. It's David. First, relative to the category, as you know from prior conversations, we deem the category to be a net positive from a client, patient, and customer standpoint as we look forward 2023 and beyond, as relates to further improvements in affordability, and given the positioning of our Accredo capabilities, a net positive for ourselves. Just grounding on that for starters in terms of the capabilities to bring this to bear. Second, 2023 represents the start of another step function as it relates to the biosimilars. Third, we will communicate our national formulary conclusions later this quarter. As you very well know, that's one dimension, and then there's client-specific formulary decisions that are made, that are underway.
To the core of your question, it will vary in 2023 between our national formulary as well as client-specific formularies on a go-forward basis. We deem it to be a net positive for the franchise in 2023. As I noted, it will present a tailwind for us in 2023. That is Humira specific or the category specific, but others will begin to ramp as we move through 2023 into 2024. I view 2023 as a transitional year for the space with acceleration. Our decisions are about to be communicated and finalized relative to formulary decisions, and they're varied at an employer or health plan level. Our national formulary decisions will be consistent across that subset of our portfolio.
Thanks for the comment.
Thank you, Ms. Gill. Our next question comes from Mr. Joshua Raskin with Nephron Research. You may ask your question.
Hi. Thanks. Good morning. The $200 million you mentioned for Centene preparation costs, is that pre-tax or after-tax? Then my real question is, you know, the outlook for Medicare Advantage for 2023, I'm curious, I know you've made some investments through this year, and you've talked about opportunities for margin next year, but I'd be curious on the growth front. If you could just give us some color on how some of the newer county expansions have gone in recent years, that'd be helpful.
Morning, Josh, it's Brian. I'll take the first part of your question, and I think David will comment on the Medicare Advantage component. The $200 million that we quoted is a pre-tax figure, and again, as we work through the detailed implementation plans in terms of rate and pace, we'll continue to refine that estimate. You should think of that as a $200 million pre-tax number for 2023 specifically. David, you wanna talk about Medicare?
Sure. Josh, good morning. So specific to Medicare Advantage, let me take it maybe a little bit in reverse order to your question, because as you articulate, we've been systematically adding new geographies, net new geographies and adjacent counties over the last several years, and successfully opening those counties in those markets. Second, as you would expect, your early sales in a net new market would tend to have a lower contribution than your sales in mature existing markets. The sheer nature of the operating cost environment and getting those businesses up and running from that standpoint.
Having said that, while we were very early in the 2023 decision-making process cycle, as every day ticks on, early precincts reporting are positive, as it relates to our current net growth algorithm and both in mature counties and markets as well as some of our new market entries. Looking at 2023, given the continued geographic expansion we've made, network improvement we've made, investment in distribution and marketing support, as well as more resources and capabilities to begin to harness some of the commercial agents to Medicare, we expect 2023 to be a year of growth for our Medicare Advantage portfolio, and we'll look forward to updating you on that as we get through the latter part of this year.
Thank you, Mr. Raskin. Our next question comes from Mr. Nathan Rich with Goldman Sachs. You may ask your questions.
Hi, this is Lindsay Golub on for Nathan Rich. Thanks for the question. Congratulations again on the Centene contract win. Could you talk through some of the opportunities for future Evernorth service expansion and just strategic collaboration with Centene?
Good morning, Lindsay, it's David. Thank you for the acknowledgement. As Brian noted earlier, we're excited and we're proud to be given the opportunity and we'll seek to earn that opportunity day in, day out. As Brian noted, before we get to the core of your question, the team is 110% focused on a successful implementation and initiation of the relationship on 1 January 2024, and is heads down relative to that. As it relates to future opportunities, I don't wanna get ahead of ourselves relative to that, but we've demonstrated over time, when we successfully partner and successfully collaborate, we have an opportunity to broaden and deepen relationships.
We enter this relationship with Centene first and foremost, needing to, wanting to, and fully committed to performing on the existing commitment. Then availing Centene as a partner relative to our Evernorth capabilities and our broad service capabilities to co-collaborate and innovate. We see opportunity over time, but we're not getting ahead of ourself. We're focused on the present, and the present is a significant win for us. I would wrap around it, our track record demonstrates deepening of relationships and broadening of relationships by co-collaboration and co-development, and that's what we will seek to do with Centene after we successfully deliver on this promise.
Thank you.
Thank you. Our next question comes from Mr. Scott Fidel with Stephens. You may ask your question.
Hi. Thanks. Good morning. Wanted to ask about the ACA Exchange market and how you're thinking about the setup for 2023 there. Obviously some moving pieces on the competitive chessboard that should be favorable for potential enrollment growth. Interested in, you know, how you're thinking about enrollment growth for 2023, and then, you know, confidence in your pricing setup for 2023. If you do end up, you know, adding more membership than expected given some of the competitor exits, you know, confidence in also achieving your target margins for that segment as well. Thanks.
Scott, good morning. It's David. Broadly speaking, we have viewed this space as a space where we have an opportunity to grow over time. As you very well know, there's been a little bit of volatility since its inception, and we entered at inception and remained in the marketplace and continued to systematically grow. We'll grow our geographies as we step into 2023. As it relates to the volume, we would expect to have net customer growth. Our current outlook is to have net customer growth in 2023, and we would expect that there would be a positive margin contribution.
As Brian and I both noted, we expect the Cigna Healthcare portfolio in aggregate to have some further margin expansion opportunity, and we believe that this subset of our space will have net positive margin contribution going forward. I'm not gonna comment in terms of the latter part of your question went back to target margins. As we continue to invest in, we know what the underlying book is performing at and what we expect it to perform at. We'll make investment decisions in 2023 for 2024.
That may dampen a little bit of the margins. Those are discretionary decisions for ongoing growth. Headline is well-positioned for 2023. Expect to have net growth and good margin performance for the portfolio.
Thank you, Mr. Fidel. Our next question comes from Mr. Gary Taylor with Cowen. You may ask your question.
Hi, good morning. One quick one for Brian and one for David. Brian, just on investment income in the quarter looked a little light, even accounting for divested assets, the return looked a little light, so just wondering if there was something there, perhaps a little non-recurring in terms of potential run rate on investment income. For David, I've had a couple clients ask lately about the DOJ intervening in the AMA lawsuit as well as the AMA joining the class action on the MultiPlan lawsuit. I guess the question really is just, you know, has the legal profile of the company changed in any material way? Just wanted to give you a chance to comment on those. Thanks.
Morning, Gary. As it relates to our investment income, within the Q3, in aggregate, the investment income did slightly trail our expectations, but that shortfall was more than offset by the favorable medical care ratio performance within Cigna Healthcare, which allowed us to outperform both our Cigna Healthcare and Enterprise income outlook. Two things that are important to keep in mind as you reflect on that, and you referenced this in your question. The first one is the Chubb divestiture that was completed on July first resulted in a step down of our investment income, and you can think of that as in the range of $50-$60 million per quarter. That's essentially removed starting in the Q3. Any comparisons to historical periods need to normalize for that factor.
The second area is within our alternative asset portfolio, which consists of, think of this as private market, non-coupon assets. This represents a minority of our invested assets, but it's subject to mark-to-market accounting per U.S. GAAP requirements. Given some of the challenges in the public capital markets this year, we had expected some downward mark-to-market adjustments in the Q3 and the Q4 , and that did transpire. Some of the downward marks were a little bit larger than what we had been projecting, but as I said earlier, our strong medical care ratio performance in the quarter allowed us to exceed our overall income and EPS outlook.
As you think about the future and trying to run rate this, if you were to remove the Chubb-related contributions from 2022, the all-in net investment income for 2023 you can think of as approximately similar to the all-in 2022 investment income. Neither a tailwind or a headwind as we step into 2023 on the investment income line. David, I'll let you comment on the Medicare Advantage lawsuit and such.
Thanks.
Thanks, Brian. Good morning, Gary. Your broader framework, Gary, I'd step back and say, we have, we do, and we'll continue to operate in an actively regulated space. Too, I point to, as we look at today and in the past, we have a strong track record as an organization of being well-governed and strong, healthy compliance-related programs. To that point and to the core of your question, I do not deem that the legal exposure, I think, is where you're going after, or the profile of the company has changed meaningfully.
In some ways, given the strategic positioning of our franchise being more services-based, I would make the argument that the legal exposure footprint on a relative basis to the space is lighter from that standpoint given the services-based nature of our portfolio is more intense and heavy. No doubt, it's an active space, has been, is, and will continue to be an active space, but we're proud of our governance and compliance functions and capabilities.
Thanks.
Thank you, Mr. Taylor. Our next question comes from Ms. Ricky Goldwasser with Morgan Stanley. You may ask your question.
Yeah, hi. Good morning. A couple follow-up questions here. Just to clarify, for 2023, is the EPS starting point that we should use $23.10? Then as we think about the Centene headwind, if it's $200 million, around 2% of earnings growth, are you assuming that excluding Centene, sort of the core business, would have grown at that long-term target of 10%-13%?
Morning, Ricky, it's Brian. Let me try to clarify some of the comments I made earlier as it relates to our 2023 outlook. Prior to the Centene contract award, the current 2023 consensus EPS estimate we see is reasonable. The last I looked, this was in the range of $25.30, you know, give or take a few cents. With the recently announced Centene contract, this will create an incremental 2023 headwind that will essentially need to be deducted from that 2023 earnings per share figure that I just referenced.
As I mentioned, as is normal, we typically start with our initial guide having some level of prudence in it, particularly since we have an at least EPS convention with the way that we communicate our outlook. Those are the different moving pieces that I would point to as you think about 2023. As I said earlier, relative to the two-year 2022 to 2024 growth rate, we would expect that to be within our 10%-13% compounded annual EPS growth rate range.
Okay. Just one quick follow-up question. As we think about the Centene contract, is there any leverage that you gain with the additional scale that you'll see across the rest of the Evernorth book of business?
Good morning. It's David. Broadly speaking, a framework of growth always presents opportunity. I think your basic tenet is positive here. Additionally, our opportunity to further enhance the value we're able to deliver to existing clients, especially those with higher government portfolios of business and/or strengthen our value proposition even further relative to winning new clients on a go-forward basis. I would give you a directional answer, not a rigid yes, no answer, but a directional answer that growth is a net positive, whether it's the ongoing investment back in innovation, the capabilities in subsectors of the space in terms of being much more government-intensive within this portfolio or otherwise. I would say net directional positive.
Thank you.
Thank you, Ms. Goldwasser. Our next question comes from Mr. Steven Valiquette with Barclays. You may ask your question.
Great. Thanks. Good morning, everybody. You know, I guess with the increase in membership guidance for 2022 and the commercial risk membership growth, year-over-year actually accelerating as the year progresses, just curious to hear a little more color just on the positive tailwinds there, kind of what's driving the extra, you know, commercial risk membership success? Thanks.
Steven, it's David. Let me talk a little more about the selling season, the dynamic and the process. As I noted in my opening, the 2022 results for commercial portfolio business, first and foremost, we're pleased with the MLR performance. We're pleased with the retention. We're pleased with the net growth, too, in 2022. A primary driver of that growth is good performance in our middle market and sustained success in our select segment. Within our select segment, we regularly offer ASO or self-funded with stop-loss, shoulder to shoulder with derivatives and specific risk alternatives. We provide choice. We provide choice to clients relative to funding.
We've designed our sales process, our underwriting process, and our solutioning process that we're able to put that choice forward. Year in, year out, it ebbs and flows between the different mix between ASO and stop-loss and risk business. We're pleased with the net risk results that underline that. But I think the overall headline is the sustained strong success of the select segment. Now more broadly, as you look at the portfolio, our fee-based business continues to grow. Brian pointed back to the meaningful growth in stop-loss. Finally, in my comments pointing toward 2023, we will have a very good national account 1 January . That's largely fee-based business.
That's retention, it's expansion, and it's new business adds, as well as addition of, large, what we would call middle market fee-based relationships going forward. So the underlying net growth is consistent. The quality is there in the MLR. Risk business you see is really fundamental strength within our select segment.
Thank you, Mr. Valiquette. Our next question comes from Mr. Lance Wilkes with Bernstein. You may ask your question.
Yeah. Congratulations on that Centene win. A great job. Two just cleanup questions. One is, in Evernorth, just understanding the driver of fees, in the Evernorth segment. And the other is just a comment on utilization. Obviously, MLR was really down this quarter. Just interested in getting any comments on relative to maybe a baseline or kind of pre-COVID levels for commercial public exchange and Medicare Advantage contrasted with sort of the non-medical products. Like, what's kind of the environment you're operating in there seeing right now? Thanks a lot.
Morning, Lance. It's Brian. As it relates to the fees in Evernorth, and you can see the strength in this line if you look at the statistical supplement in terms of fees and other revenue with strong 16% quarter-over-quarter, 21% year-to-date growth. There's a few different components that contribute to this. One, this is where our MDLIVE business shows up, and we continue to see strong growth throughout the year in utilization of our MDLIVE services. Secondly, we have a number of Express Scripts or pharmacy benefit services clients who choose a pure fee-based relationship with us.
We offer choice relative to how they wanna work with us, as some of them might want a formulary or a network-only relationship, and that shows up in this line item. Our eviCore business in terms of medical benefit management, some of the post-acute care solutions, et cetera, all roll up into this line item. All these things in totality are showing nice growth for the Evernorth business. As it relates to your second question, I think that was pointed at Cigna Healthcare more specifically in terms of the utilization environment, the Q3 did run favorable to our expectations. Most of that favorability was in the U.S. commercial book of business with our government lines essentially in line with expectations.
Within the quarter, both COVID and non-COVID costs in the U.S. commercial book were favorable to our expectations. Non-COVID favorability was predominantly driven by inpatient and emergency room. On the COVID side of the house, we saw Q3 COVID-related costs running at a very comparable level to what they were in the Q2 , whereas we had assumed a bit of an uptick. So broadly speaking, that's how I would summarize what we saw in the Q3. All in, our commercial book of business is running just slightly above what a pre-pandemic baseline would have been trended forward, to your question there, with Medicare a touch below that.
Great. Thanks a lot.
Thank you, Mr. Wilkes. Our last question comes from Dave Windley with Jefferies. You may ask your question.
Hi, thanks for squeezing me in. I joined late, so I apologize if this has been asked, but as you think about 2023 and, you know, kind of Fed pushing to slow labor market and potential recession implications, will you be thinking about recession possibilities as you set your guidance for 2023? How do you think the business is positioned to be resilient against that?
Dave, good morning. It's David. I think a really important question and that we didn't spend time on that, so thanks for the opportunity. First, from our point of view, there's little doubt the economy has been confronting some challenges. Recession, non-recession, there's been some challenges. To date, important grounding, we've seen little direct impact for the demand of our services or the underlying performance for our portfolio, right? Movement in costs here or there, but broadly speaking, we've seen little direct impact. As we look forward, by and large, we still see an environment where net-net, employers are more oriented in terms of maintaining and/or hiring employees seeking to get to full employment. We do see instances where that has slowed. We do see instances where employers have put in freezes.
When you balance the portfolio as a whole right now, there's still a net hiring environment that sits in front of us. Now, not as of today. As we look forward, we absolutely play through scenarios that could have further softening of the economy or recessionary impact. At this point, we believe, given the visibility we have into the starting point of 2023, with the net growth we expect to step in the year with, coupled with the strength that we expect to end 2022 with, those two points and the various levers we have within our diverse services portfolio and benefits portfolio, we believe we'll be in position to deliver another strong 2023.
Ending with, we acknowledge the fact that the economy is in a bit of a challenging environment in the current state, but all in, we believe our portfolio will be durable and is in position to perform next year because of the strong start we'll have to the year and the various levers we have to manage in our portfolio.
Great. Thank you.
Thank you, Mr. Windley. I will now turn the call back over to David Cordani for closing remarks.
First, let me thank everybody for joining our call today, and I'll just wrap up with a few thoughts. First, our business is performing well. Our new collaboration with Centene is great evidence of the strength of our value proposition and how it continues to resonate in the market. We're growing with high levels of retention and winning new clients. We're performing well in this dynamic environment, and our sustained, disciplined execution is benefiting those we serve as well as our shareholders. We are delivering for our shareholders and remain on track for our full year adjusted EPS outlook of at least $23.10, which is elevated from our prior outlook, and we are confident we are well positioned over the long term to continue to deliver on our annual adjusted EPS growth of 10%-13% plus our meaningful dividend.
This is all possible because of the breadth of capabilities we have across our organization, our proven commitment to innovation, but most importantly, the dedication of our more than 70,000 coworkers across the globe. I personally appreciate our team and what they do every day for our clients, our partners, our customers, and patients, and I thank them for the commitment to making a positive impact on people's lives each and every day. We thank you again for your interest in Cigna, and we look forward to continuing our conversation as we go into the latter part of this year. Have a good day.
Ladies and gentlemen, this concludes Cigna's Q3 2022 results review. Cigna Investor Relations will be available to respond to additional questions shortly. A recording of this conference will be available for 10 business days following this call. You may access the recorded conference by dialing 800-819-5739 or 203-369-3350. There is no passcode required for this replay. Thank you for participating. We will now disconnect.