CVS Health Corp (CVS) — Q3 2025 Earnings Call Transcript

Good morning, and welcome to the CVS Health Third Quarter 2025 Earnings Call and Webcast. I'm Larry McGrath, Chief Strategy Officer. I'm joined this morning by David Joyner, President and Chief Executive Officer; and Brian Newman, Chief Financial Officer. Following our prepared remarks, we'll host a question-and-answer session that will include additional members of the leadership team. Our press release and slide presentation have been posted to our website, along with our Form 10-Q filed this morning with the SEC. Today's call is also being broadcast on our website, where it will be archived for 1 year. During this call, we'll make certain forward-looking statements. Our forward-looking statements are subject to significant risks and uncertainties that could cause actual results to differ materially from currently projected results. We strongly encourage you to review the reports we file with the SEC regarding these risks and uncertainties, in particular, those that are described in the cautionary statement concerning forward-looking statements and risk factors in our most recent annual report on Form 10-K, our quarterly report on Form 10-Q filed this morning and our recent filings on Form 8-K, including this morning's earnings press release. During this call, we will use non-GAAP measures when talking about the company's financial performance and financial condition. And you can find a reconciliation of these non-GAAP measures in this morning's press release and in the reconciliation document posted to the Investor Relations portion of our website. With that, I'd like to turn the call over to David. David?

Thank you, Larry, and good morning, everyone. This morning, we are pleased to report another quarter of solid results, once again reflecting the power of our diversified business and progress on becoming the most trusted health care company in America. In the third quarter, we delivered adjusted operating income of $3.5 billion and adjusted earnings per share of $1.60. In addition, for the third consecutive quarter, we are increasing our full year 2025 adjusted earnings per share guidance to a range of $6.55 to $6.65, up from our previous range of $6.30 to $6.40. Over the past 12 months, we have been intensely focused on executing against our commitments to our customers, partners, colleagues and shareholders. We are building momentum across the enterprise and feel a growing excitement about the opportunities ahead for CVS Health. We are incredibly proud of what we have accomplished so far this year. While we are encouraged by our progress, we maintain a disciplined and cautious outlook as we position our business for another year of strong performance in 2026. This transformation is clearly visible within our Aetna business where after a challenging 2024, there is renewed vigor and optimism about the future. The Aetna team continues to drive impactful and exceptional results. Aetna is once again the industry leader amongst national payers for 2026 Medicare Advantage Stars Ratings, even with CMS recently announcing that cut points for stars continue to become more challenging. Based on the current membership, we expect over 81% of our Medicare Advantage members will be in plans rated 4 stars or higher with over 63% of them in 4.5 star plans, nearly double the industry average. This result is not just a point of pride, but another proof point that our ability to effectively collaborate across the enterprise allows us to deliver exceptional quality and service, drive down the cost of care and remove friction from the health care system. We are still in the early stages of the 2026 annual enrollment period, but we remain confident that our thoughtful approach to our geographic footprint, benefit design and pricing positions us well for another year of recovery. In my first year as CEO, I have pushed our team to act with urgency and focus as we execute on opportunities to improve our business. This means making thoughtful and difficult decisions, such as exiting our individual exchange business or taking advantage of market opportunities like our acquisition of the Rite Aid assets. In a similar way, as we outlined last quarter, we are moving with urgency to address pressures in Health Care Delivery. During the quarter, we recorded a $5.7 billion goodwill impairment within Health Care Delivery. I want to be clear that this business' performance in the quarter was in line with our most recent expectations. However, our decision during the quarter to temper Oak Street Health Clinic growth over the next few years was the primary reason for recording this charge. Despite this update, value-based care remains a critical component of our strategy. The reasons to believe in this business have not changed, but the marketplace is evolving and we are adapting our strategy to get financial performance back in line with our expectations. We understand the challenges at Oak Street Health and have taken actions to improve performance in both the near and long term. We continue to strengthen our Health Care Delivery business through investments in technology, a new leadership team and fair and equitable contracts with our payer clients. Turning to Pharmacy Services. We're incredibly proud of the meaningful impact we've had on drug costs in this country. As you've seen with our recently announced IVF initiative with the administration, we are strong supporters of the administration's focus on lowering brand prices in America. This is important for our patients, our customers and for our business model. By tackling branded pharmaceuticals and equitable pricing strategies that have left Americans carrying the financial weight of global drug innovation, the government is helping to relieve a long-standing burden on U.S. consumers and businesses. We believe that over time, the administration's actions can create a new lower ceiling price in the U.S. in which pharmacy benefit managers will continue to negotiate and further reduce costs for their customers and consumers. This has been our job for more than 3 decades, and we have been tremendously successful at achieving durable results. We believe these actions are good for us, for our customers and for consumers, and we are encouraged to see the impact they may create for the industry. As the leading health care consumer company, we've been working diligently for years to lead with greater transparency and savings for consumers at the pharmacy counter. We were at the forefront of this transition with more than 25 million members who benefit at the pharmacy counter from our lowest net cost through point-of-sale rebates. This includes our Aetna fully insured commercial members who we transitioned in 2019 and the benefit design we offer our own colleagues. Two years ago, we continued our innovation leadership when we introduced our new TrueCost model, which guarantees a net cost for each individual drug, delivering drug pricing transparency for our clients and consumers. We are encouraged by recent announcements that others are following us on this path. We know that this is the transition that consumers want and is also important for the future of our business. We're incredibly encouraged by the path Caremark is on. However, we acknowledge there are near-term market dynamics from a few of our client contracts that have resulted in a revision to our guidance and will impact our near-term growth rate. While incorporating this, as Brian will discuss later, we continue to expect meaningful growth in enterprise earnings next year. We are working diligently to recontract over the next few years and resolve this issue. Importantly, clients, including the most sophisticated buyers of pharmacy benefit services, continue to see the tremendous value we provide, as evidenced by another strong selling season. We have achieved new client wins of nearly $6 billion and are closing out another selling season with retention in the high 90s. I am incredibly bullish about the road ahead and believe we will continue to lead this industry given our unique advantages and insights. Turning to PCW. Our leadership is clear in the retail pharmacy market as we work towards a more sustainable and transparent future. Our deliberate strategic decisions, intentional investments, best-in-class drug purchasing and superior customer service have meaningfully improved our differentiated position in the market. Once again this quarter, CVS Pharmacy delivered solid performance, including pharmacy share gains. This is a testament to the strength and scalability of our model as well as the commitment of our engaged colleagues. We play a critical role in improving the health of millions of Americans by providing convenient health services, including vaccinations. Our 9,000 pharmacies are the front door to our enterprise. They are a differentiator for our business and a force multiplier towards improving the health of the communities that we serve. For CVS Health, being the most trusted health care company in America means improving health, simplifying care and delivering a quality experience every day. We do not take this responsibility lightly and it is this team's firm belief that we must drive the evolution of health care forward in the U.S. We have unique capabilities to achieve all of those goals. The strength of our diversified businesses continues to set us apart, enabling us to deliver strong results even in this dynamic environment. The progress we've made this year is fueling momentum and our disciplined execution positions us for another year of strong performance in 2026. We are working to simplify health care and are bullish about the opportunities we see to lower the cost of care and drive innovation. Our future is bright because of the work of our more than 300,000 colleagues who take care of their friends, families and neighbors and communities across our country. We look forward to sharing more on our longer-term plans at our Investor Day on December 9. With that, I'd like to hand the call over to Brian. Brian?

Thank you, David, and good morning. I will cover 4 key topics in my remarks. First, an update on our third quarter results. Then I'll discuss cash flow and the balance sheet. After that, I will provide an update on our revised financial outlook for the remainder of 2025. And finally, I'll wrap up with a brief discussion on high-level headwinds and tailwinds as we look ahead to 2026. As David mentioned, we are pleased to report another quarter of solid performance and to deliver a third quarter in a row where we beat and raised expectations as we continue to focus on building a track record of consistent success. We improved our full year outlook for revenue, adjusted EPS and cash flow from operations and are building positive momentum as we close out the year. Let me start with highlights on our enterprise results in the quarter. Third quarter revenues achieved a new record of nearly $103 billion, an increase of approximately 8% over the prior year quarter driven by revenue growth across all segments. Adjusted operating income of approximately $3.5 billion increased approximately 36% from the prior year quarter, primarily driven by an improvement in our Health Care Benefits segment. We delivered adjusted EPS of $1.60, an increase of nearly 47% from the prior year quarter. Finally, we generated year-to-date cash flow from operations of approximately $7.2 billion. Turning now to each of our segments. In Health Care Benefits, we generated nearly $36 billion of revenue in the quarter, an increase of over 9% from the prior year. This increase is primarily driven by our government business, largely related to the impact of the Inflation Reduction Act on the Medicare Part D program. We ended the quarter with medical membership of approximately 26.7 million, which was flat sequentially and decreased approximately 445,000 members from the prior year quarter. This year-over-year decrease is primarily driven by declines in our individual exchange and Medicare product lines, partially offset by growth in our commercial fee-based membership. Adjusted operating income in the quarter was approximately $314 million, a substantial increase from the adjusted operating loss recorded in the prior year quarter. Our medical benefit ratio was 92.8%, a decrease of 240 basis points from the prior year quarter results of 95.2%. The change was driven by the favorable year-over-year impact of premium deficiency reserves, higher favorable prior period development and improved underlying performance in our government business. These increases were partially offset by changes in the seasonality of the Medicare Part D program due to the impact of the IRA and the impact of higher acuity in the individual exchange product line. Our medical benefit ratio this quarter was impacted by approximately 100 basis points due to provider liabilities for matters dating as far back as 2018 and worsening individual exchange risk adjustment expectations based on the Wakely data. Each of these 2 items were roughly equivalent. Medical cost trends in the quarter remained elevated across all products, but were modestly favorable relative to our expectations, primarily driven by our individual Medicare Advantage book. Days claim payable at the end of the quarter was approximately 42.5 days, an increase of approximately 1.6 days sequentially, primarily driven by the partial release of premium deficiency reserves established in the first half of 2025 as well as an additional day in the third quarter compared to the second quarter. We remain confident in the adequacy of our reserves. Shifting now to our Health Services segment. During the quarter, we generated revenues of over $49 billion, an increase of over 11% year-over-year. This increase was primarily driven by pharmacy drug mix and brand inflation, partially offset by continued pharmacy client price improvements. Adjusted operating income in the quarter of approximately $2.1 billion decreased 7% from the prior year quarter, primarily driven by continued pharmacy client price improvements, partially offset by improved purchasing economics. Performance in our Health Care Delivery business during the quarter was broadly in line with our expectations. Total revenues grew approximately 25% compared to the same quarter last year, excluding the impact of our exit from our CVS Accountable Care business earlier this year. This increase was primarily driven by patient growth at Oak Street and increased volumes at Signify. During the quarter, we made certain strategic changes in our Health Care Delivery business, including the decision to reduce the number of new Oak Street clinics we expect to open over the next several years. These changes necessitated a quantitative assessment of the carrying value of goodwill in our Health Care Delivery reporting unit, which resulted in a goodwill impairment charge of approximately $5.7 billion during the quarter. We are focused on improving financial performance in our Health Care Delivery business. As discussed last quarter, we have and continue to take actions at Oak Street to enhance our operations. During the quarter, we completed a comprehensive review of our Oak Street clinic footprint. As David mentioned, this is core to our approach of evaluating each of our businesses, identifying strengths and making decisions to drive improved execution and performance. Following our review, we made the difficult decision to close underperforming clinics where we do not see a reasonable path to sustainable margins. To be clear, we view value-based care as a critical component to our Medicare strategy and expect the actions we are taking to support improved financial performance beginning next year. Our Pharmacy & Consumer Wellness segment delivered another strong quarter. We generated revenues of over $36 billion, an increase of nearly 12% versus the prior year quarter, primarily driven by pharmacy drug mix and increased prescription volume, partially offset by continued pharmacy reimbursement pressure. Revenues in the quarter increased over 14% on a same-store basis. Our retail pharmacy script share grew to approximately 28.9% as our emphasis on operational excellence and superior customer experiences enables us to benefit from pharmacy market disruption. Same-store pharmacy sales in the quarter grew nearly 17% compared to the prior year, driven by pharmacy drug mix and a nearly 9% increase in same-store prescription volumes. Same-store front store sales increased 150 basis points versus the prior year quarter. Adjusted operating income decreased approximately 7% from the prior year to approximately $1.5 billion. This decrease was primarily driven by continued pharmacy reimbursement pressure and increased investments in colleagues and capabilities. These items were partially offset by increased prescription volume. Shifting now to cash flow and the balance sheet. We generated cash flows from operations of approximately $7.2 billion year-to-date through the third quarter. We have distributed approximately $2.6 billion in dividends to our shareholders year-to-date, and we ended the quarter with approximately $2.3 billion of cash at the parent and unrestricted subsidiaries. We continue to meaningfully improve our leverage ratio, supported by our strong year-to-date performance and expect to make further improvement next year as we grow enterprise earnings driven by margin recovery in our Aetna business. Shifting now to our revised outlook for 2025. We are increasing our full year 2025 guidance for adjusted EPS to a range of $6.55 to $6.65, an increase of $0.25. This update reflects our third quarter performance and our revised expectations for the remainder of the year, which continue to maintain a prudent outlook on medical cost trends and macro factors. We now expect full year total revenues of at least $397 billion, an increase of nearly $6 billion driven by increases across all segments. In our Health Care Benefits segment, we now expect full year adjusted operating income of approximately $2.72 billion at the low end of our guidance range, an increase of approximately $300 million reflecting our performance in the third quarter and improved expectations for the remainder of the year. We continue to project our full year 2025 medical benefit ratio at the low end of our Health Care Benefits adjusted operating income guidance range to be approximately 91%. This outlook continues to maintain a thoughtful and prudent view on medical cost trends through the remainder of the year. In our Health Services segment, we now expect full year adjusted operating income of at least $7.1 billion, a decrease of approximately $240 million from our prior guidance. This update reflects our latest expectations for performance that David highlighted in his remarks. Importantly, we continue to make progress evolving our contracting and pricing models to respond and adapt to market dynamics. We are confident we're on the path to lead the evolution with our new TrueCost model, which guarantees a net cost of each individual drug, driving drug pricing transparency for our clients and members. The outlook for our Health Care Delivery business remains largely unchanged. Lastly, in our Pharmacy & Consumer Wellness segment, we now expect full year adjusted operating income of at least $5.95 billion, an increase of approximately $270 million from our prior guidance. This increase reflects our performance in the third quarter and our revised expectations for the remainder of the year, while continuing to maintain a prudent outlook for the rest of the immunization season and potential impacts to the consumer environment. In aggregate, we now expect full year enterprise adjusted operating income to be in the range of $14.14 billion to $14.31 billion. We are also increasing our expectations for full year cash flow from operations to be in a range of $7.5 billion to $8 billion. Additionally, we now expect our full year adjusted effective tax rate to be 25.3%, an improvement of 40 basis points. You can find additional details on the components of our 2025 guidance on our Investor Relations website. Before we open the call up to Q&A, I also want to provide an update on some of the key headwinds and tailwinds for 2026. Consistent with past practice, we expect to provide formal 2026 guidance at our Investor Day in December. Beginning with our Health Care Benefits business, we expect another year of meaningful margin improvement at Aetna. This includes another year of progress in our Medicare Advantage business, supported by our disciplined approach to plan design and footprint in individual as well as repricing opportunities in our group business. We also expect a tailwind from our exit of the individual exchange business. Although our conversations with our Medicaid state partners continue to progress and this business has performed in line with our expectations this year, we are taking a cautious outlook in light of the broader pressures across the industry. In our Health Services segment, we expect improvement in our Health Care Delivery business, primarily driven by Oak Street Health. In our Caremark business, we expect modestly lower growth as we continue our work to transition our contracts towards drug level pricing over the next few years. Altogether, we expect the segment to deliver low single-digit adjusted operating income growth next year. And in our Pharmacy & Consumer Wellness segment, we are encouraged by our strong performance this year and expect this momentum to continue into next year. While challenges, including reimbursement pressure and the impact of shifting consumer dynamics remain in this business, we currently expect the trajectory to improve relative to our long-term expectation of a 5% decline. I would also remind everyone that consistent with past practice, the impact of prior year reserve development and other out-of-period items should be removed when considering an appropriate baseline for bridging to 2026. As of the end of the quarter, these items contributed approximately $0.45 to our year-to-date results. Altogether and after adjusting for these items, we currently expect a reasonable starting point for our 2026 adjusted EPS guidance to reflect mid-teens growth. We will provide formal guidance at our Investor Day on December 9. Overall, we are encouraged by the year-to-date performance of our diversified enterprise and are confident we are taking the right steps to position us for both near- and long-term success. We recognize the importance of establishing credible commitments and expect to continue this philosophy as we establish future financial targets. With that, we'll now open the call to your questions.

I would like to begin with your comments regarding the PBM aspect. First, concerning the $240 million you mentioned and our shift towards transparency with TrueCost, should we expect to face ongoing challenges as we transition these contracts? This relates to Brian's comments about '26 as well. Additionally, how should we view the future PBM economics under a TrueCost model, not just from your perspective as the PBM, but also in light of the plan sponsors' needs? Many plan sponsors use rebates to reduce premiums, so what does the future look like for them, along with your economics on the PBM side?

Yes. Lisa, great question and something that obviously we're prepared to address both today as well as where we see the marketplace evolving. But let me first start with, I think if you look at the headwinds that we're seeing specifically within the PBM, this does reinforce the strength of a diversified company. So this is the third consecutive quarter where we both exceeded and raised guidance. It highlights the focus and the commitment that we've made around building trust and credibility. So I think that is what I want to make sure is known that there's performance again across the broader enterprise. A couple of things as it relates to the PBM and specifically to your question about the future. Over the course of my 30-year career, Caremark has consistently driven innovation and been able to adapt to the changing market. The drive is not just changing the way in which our teams are working, but we've talked over the last couple of years about changing the PBM model. And part of this is the TrueCost transition to what I believe will be the pricing model of the future. So I remain confident that Caremark will deliver both on the strong earnings and cash flow for the foreseeable future. And I think it's going to be reinforced in what we've said about the selling season. Even in light of some of the challenges around the industry, we delivered $6 billion of new wins and had a high retention rate in the 90s. So I'm going to let Brian speak to some of the financials and some of the pressures, then I'll have Prem speak more broadly to the last question about where this is going from a PBM model.

Thanks, David. And Lisa, thanks for the question. I think if we take a step back, I think it's actually important to provide some context on the historical industry practices. Historically, the norm in the industry was to use an aggregate market basket-based approach to structure guarantees. And I think as we highlighted in our prepared remarks, throughout the year, we've observed a combination in mix of drugs, in utilization patterns that differed from our prior forecast. And given the market basket structure underlying the client guarantees, those dynamics are putting pressure on the contracts David actually mentioned in his prepared remarks. We have been closely monitoring the trends. While we acknowledge the impact that the market basket had on guarantees for some of our contracts, we believe we had a feasible plan to address the emerging challenges. As we ended the quarter, we recognized that the mitigations we identified did not materialize as quickly or have the expected impact. This was the reason we modestly missed our third-quarter expectations. We have also updated our expectations for the full year, which I mentioned in my earlier comments, and this will influence our near-term growth outlook as we restructure contracts over the next couple of years. Prem, could you elaborate on the value Caremark provides and the changing model?

Yes. Lisa, thanks for the question. And just to answer directly on the future PBM economics, as you know, the PBM industry has been and will continue to be an extremely competitive space where we deliver tremendous value to our customers and deploy that value to them. If you think about from my perspective, what Caremark has done over the course of the last many decades is we continue to focus on our clients' biggest problems, which is the high cost of branded drugs. As we've said, 10% of drugs drive 88% of our pharmacy costs in this country. And we're going to continue to lead and be a leader in this space. Eighteen months ago, we launched Cordavis to target the largest specialty drug in the country. We provided our clients with over $1 billion in savings by switching all products to a lower cost, achieving an 81% reduction in WACC compared to the originator. Earlier this year, we also focused on GLP-1 medications, which represent around 15% of our clients' costs. We optimized our formulary in the weight loss category, resulting in cost benefits for our clients. This adjustment positively impacted the market as well, leading to reduced net prices across the entire category. This is the essential role of PBMs; they drive competition, a practice we've maintained for the past three decades and will continue into the future. As it relates to the value and how the economics kind of pass through from us and our clients and how that plays out in the marketplace, at the end of the day, the problem in this country still is health care is unaffordable. And what you're describing is really kind of the spread of which is a member out-of-pocket or a planned premium. And from our perspective, what we're doing with TrueCost, which we launched 2 years ago, was very deliberate, and it was driving greater transparency and making sure that consumers and clients had the benefit of that transparency while, again, maintaining our ability to create the competition and lower the net cost of drugs. As David said in his prepared remarks, we have over 25 million customers and consumers that are in our point-of-sale rebate program. Aetna has launched point-of-sale rebates as far back as 2019. So this is something that we have been really focused on where we get the consumers the lowest possible price at the counter because we know medicines in this country help lower the cost of overall health care expenditures and it's critically important. And lastly, I'll say, as all the things have been happening with the administration, we're excited to play an active role in making medicine more affordable in this country. We think we will continue to play that role. And we love the fact that they are going after the inequity across countries that you've seen and the price disparities that exist. So more to come, but I would say the PBM business continues to be a very competitive space, continues to have durable margins and continue to be a very necessary component of how we deliver care and lower costs in this country.

And maybe just one final comment. I think it's important to note that we saw this trend several years back, which is part of what we're trying to do within retail moving to CostVantage and where the PBM was driving towards TrueCost. So we saw where the marketplace is going. We led the market. We're in the middle of that transition to the model of the future. And again, I think the near-term headwinds is not an implication on the long-term viability of the PBM model. Thanks, Lisa.

I wanted to ask about the PCW business. It looks like the third quarter exceeded your expectations, and you project about 3% growth for the fourth quarter. Could you explain what factors support your confidence in that fourth quarter growth, especially considering the impact of reduced vaccine volumes on OI and the positive effect of the 600-store file acquisition from Rite Aid for the fourth quarter, along with its EBIT implications through 2026?

All right. Thanks, Justin. I appreciate the question on PCW. So Prem, do you want to talk specifically about the growth rate?

Yes, Justin, thank you for your question. As you remember from previous analyst days, we have been very intentional with our strategy to improve our business and get back to a better performance than minus 5%. I'm extremely proud of our leadership team and the strong execution we have achieved. We have a solid strategy based on healthcare engagement, which we truly believe in. We currently have over 9,000 community pharmacy locations where we can effectively serve patients and members, providing unique services. I'm proud to state that we are operating the best pharmacy in the country, functioning on a national scale. We have excellent consumer engagement and strong clinical expertise that we are bringing to the market. This builds a high level of trust among our consumers, allowing us to create additional value across different areas of our business. When you think about what's driving that, first, from a business perspective, we were very deliberate in our investments in technology and taking care of our colleagues. We have over 200,000 colleagues in 9,000 of these stores that continue to deliver best-in-class service. And then secondly, we were focused on how we can engage and better engage consumers in a differentiated way. So all in all, it's going really well. As it relates to the quarter, we delivered a strong quarter despite some of the persistent reimbursement pressures that we faced. If you look at the script growth, we had top line growth about 11.7%. And our pharmacy market share is now at 28.9%. Rite Aid was one of the drivers that was in that as we kind of moved that business into our operating model. But just remember, the strong foundation, the strong service enabled us to really be able to do that in a much more effective way. And then if you think about the immunization piece, we continue to be a trusted choice and a convenient option for those choosing to get vaccinated. The market demand is down year-over-year, but we've been able to offset that with a market share growth in our channel. We've seen approximately 400 basis points of market share growth inside of CVS. Secondly, if you think about our front store, we still have strong momentum. We're posting another positive comp for the second quarter in a row and improved from last year. We grew our customer base 2.6% versus last year. We increased trips 2.7% versus last year. And our retail market share on the front store has gained by 2 basis points versus last year. So we're continuing to focus on delivering value being where consumers want us to be in the front store by driving loyalty and improving our value proposition. And I'd just say, all in all, we're incredibly proud of the results, incredibly proud of the leadership team and the focus that we have here, but we still have work to do to stabilize this business over time. And Brian, I'll hand it over to you for a couple more comments.

Yes. No, just, Justin, in terms of the outlook, the strong performance Prem talked about in the quarter, we lifted our guide for the segment and it's now sitting at a growth of 3% for the year. And I'd remind you, that's an 8% swing from our initial expectations of down 5%. So we're seeing that business improve, and we'll talk more about it come December 9 at Investor Day.

Yes. Maybe just closing out on the PCW conversation, this is a business that we've been investing in over the last several years. I think some of this has come to fruition in terms of the investments we've made in becoming best-in-class. So we've talked about this in the opening comments that the 9,000 stores is our front door to the enterprise. And when this business runs well, it does become the force multiplier to improving health and our focus on serving the community. So really excited about the performance, and we'll share obviously more, as Brian said, on Investor Day about the future direction of this business.

Sorry for the difficulties there. Just to kind of come back to that point a little bit. I think with the first couple of quarters of the year, you sized in each quarter that, I guess, on a continuing basis, there was around $500 million core upside that you weren't taking through into the guidance. Wondering if there's an equivalent amount, if you think about kind of excluding the items that you called out around the exchanges and around the out-of-period settlements that you'd cite for Q3? And I guess how do we reconcile that versus the raise that you made? And I guess just one clarification as we're getting a lot of questions on it. This mid-teens EPS growth that you're framing for 2026, is that after taking the $0.45 out of the baseline? Or is that off of this year's guidance as you currently revised it?

Yes. To take your last question, Stephen, you take the midpoint of the guide, which is $6.60, back off the $0.45 and then you can grow mid-teens off of that. And the way we got to the $0.45, I think going into the quarter, we had about a combination of net both positives and negatives. If you take some of the out-of-period risk adjustments and revenue adjustments net of the upside, we'd be about $900 million coming out of the first half of the year. You take the $150 million of the provider settlements, that's how we get to $750 million roughly or the $0.45 as we adjusted, which I just walked you through.

I know Lisa had asked about the PBM headwinds that you had been discussing. I want to talk a little bit more about the PBM tailwinds. Beyond Cordavis, what are you seeing broadly from a specialty growth perspective? And can you talk about some of the strategic advancements you're making to continue to benefit from what has obviously been an extremely strong overall market growth?

Prem, do you want to take that?

Sure. Thanks for the question, Michael. There are a couple of key points to consider. From a positive standpoint, we see significant opportunities to further reduce costs for our customers. As you know, when we lower costs for them, the PBM industry tends to benefit as well. First, the biosimilar pipeline still holds great promise, with projections indicating $100 billion in biosimilars coming by the end of this decade or early 2030 to 2031. We are actively exploring ways to enable and drive down costs related to biosimilars for our customers. Additionally, we believe there are further opportunities to offer value through other specialty drugs and generic medications that are entering the market. And let me just take a couple of seconds to talk about our CVS Specialty Pharmacy business. It continues to be a leading asset in the specialty pharmacy arena. It's a leader and a key overall performance driver of Caremark, and we expect it will continue to be helping to support the members that they serve. Remember, these 1% or 2% of the population that utilize specialty pharmacy benefits typically drive 50%, 60% of all of health care expenditure. And so our business continues to perform really well. And we have a strong track record of continuing to gain access to new limited distribution drugs in that space. We continue to build technology that makes it seamless to transition patients from branded products to biosimilars. And lastly, our operating platforms, a tremendous amount of credit goes to our leadership in this business is driving to a much more tech-driven AI native platform that's driving and really taking a lot of the work out a lot of operations and something that was one of the most complex parts of health care, which is effectively trying to drive these medications into the patients' homes. And so we continue really proud of those points as it relates to that. We also see opportunities in the PBM for what I would say is efficiencies and optimization over time, where we see the opportunity to leverage technology and other things to also play a role. And lastly, I think the PBM sales season is great evidence that we continue to focus on our customers. We're winning net new customers and delivering the value that they're asking for us. So we had over $6 billion of net new sales for 2026. So continue to be excited about this industry. It remains to be highly competitive as it always has been. And we continue to remain to be a leader in driving that competition and driving affordability for our customers and creating innovative solutions that they can deliver into the marketplace.

Thanks, Prem. Maybe just one additional comment on the PBM because there's obviously emerging models that we're seeing around the DTC. So 2 things I would point out. One is we were the first large provider to join the NovoCare program for GLP-1s. So that's again our push into lowering the cost of these obesity products in the direct-to-consumer market. And then the most recent announcement we made with the administration with respect to the IVF therapy, again, our specialty pharmacy playing an essential or critical role in the rollout of that program as we serve consumers and our customers.

I'd like to return to Caremark and ask you to clarify the extent to which you're seeing pressure from adoption of TrueCost versus change in mix. If it's TrueCost, how much of that was CVS? I'd expect you were ahead of that versus others or independents that you're enabling. And then if more change in mix, are you seeing that changes to GLP-1 formulary or biosimilar private label is having an impact on rebate guarantees?

Yes, Eric. Thanks for the question. First off, let me be clear, this is not from TrueCost. The TrueCost model is not what's driving this. As you know, in the legacy PBM models, in the PBM marketplace, we predict and try to drive rebate guarantees, which is a way in which we derive the value for our customers. In that case, we had probably 3 primary drivers of some of the pressure. One, the slower growth of GLP-1s that we're seeing in the back half, primarily driven from we expected a little bit more of the compounding volumes to come back into the benefit, which we're not seeing. Secondly, we had a couple of products on the autoimmune category not related to Cordavis, but drivers of a couple of products that we're driving that. So one is in the autoimmune category and one is in the HIV category. So this is not from TrueCost. It is something we're working with our clients actively adjusting our guarantees appropriately as we move forward, but create a little bit of pressure in the short term.

I wanted to ask about the recontracting efforts at Oak Street and understand the room for improvement there. So first, can you share the pretax operating losses of that business today? And to the extent you had problematic external membership this year, did you see the needed changes made to benefits for the 2026 plan year? And if not, can you help us understand what contracting changes you're making, including how much risk is shifting back to your Medicare Advantage partners?

Thanks very much. I'll let Prem talk to the business and the evolution. We don't share the pretax loss, but I think we've been very focused on the Oak Street business. Once again, the impairment we took was at the HCD level. But we took a look at clinic growth and really by slowing the clinic growth, the terminal values, what drove the impairment charge. And we believe we're getting the Oak Street business in particular on the path to profitability. Prem, do you want to give a little color on the business?

Yes, thank you for the question. To be clear, the performance this quarter was aligned with our adjusted guidance. Regarding value-based care, as David mentioned earlier, it remains a key part of our strategy. We understand the significant impact it can have on the healthcare system, as well as its importance to patient experience, outcomes, and costs. We are focusing on three or four key areas at Oak Street Health, specifically concerning the payer contracts. One, we won't comment on any specific contracts, but we're focused on ensuring that we have alignment with our payers on ensuring the sustainability of these agreements and having fair and equitable terms for the value that we provide. So we're continuing to work on that with our payers and continue to drive that forward. But the 2 other areas I think that are really critical is we are really proud of our clinical model that we have. We continue to enhance our technology and our operations to drive an enhanced model in which we'll ultimately lower cost and improve quality of our members. And lastly, on the center footprint, listen, at the end of the day, the world has changed in value-based care. So we're being very prudent and we've slowed the number of clinic growth that we had. And we're focused on growing membership inside of our clinics. And so from our perspective, those things are all the components that are driving. And we expect the Oak Street business to improve year-over-year. And lastly, as it relates to V28, it's in line with our expectations of the impact of that as we think about that business.

David and Brian, my question is kind of focused on the retail pharmacy business. And you talked about how 2026 is going to show an improvement from the long-term guide. I guess I would ask if you can comment, how far are we away from like the long-term guidance of down 5% not being the case anymore? And given the PBMs are paying pharmacies more money and CostVantage is taking root across different payer segments, does earnings growth start to look more like script growth in that segment? I'll stop there.

Thank you, George, for the question. At a high level, when we announced CostVantage, it was part of our long-term strategy, and we are currently the largest purchaser in the country. We believe we offer the best cost of goods in the market. As our performance improves, payers will benefit from that. Now as we enter the second year of this initiative in 2026, we will provide more insights during Investor Day regarding the business's performance. Ultimately, we anticipate a better alignment between the actual cost of goods and the reimbursement for the services we offer.

And so, George, remember the three primary challenges in the retail business. When we started CostVantage, we faced one significant challenge, which was reimbursement pressure, but we had three supportive factors offsetting it. First, we consistently drove increased volume into our stores through script growth. Second, we implemented productivity initiatives that reduced our costs associated with delivering those scripts. Lastly, we saw improvements in the cost of goods. All these factors combined resulted in a challenge we are trying to address. As for CostVantage, it will take a multiyear journey to reach a point where the erosion of reimbursement matches our improvements in the cost of goods. We are making good progress, but reimbursement pressure remains a focus in our underlying business.

Yes. And George, maybe one final comment. Your thesis is right, which is our growth should be tied to script growth. And as we get CostVantage rollout across our payers, that will become part of the growth. The second part is the services we're going to provide inside the pharmacy. So if you look at the stars performance within Aetna, a lot of this was driven because of the collective enterprise effort and the services and the specific programs that have been delivered and launched within retail to engage and drive better performance around adherence and the other quality measures. So that is the next frontier, and this is how we're going to collectively drive the value across the enterprise.

I want to ask a little bit about what's embedded in your '26 comments for the Health Care Benefits around MA margin expansion. Can you get to be profitable next year? And also enrollment, I know enrollment is not over yet, but your sense of where your enrollment goes in individual MA next year.

Thanks for the question. As we think about the guide, which we'll really get into in December at Investor Day, but in HCB, which you asked about, I would say we expect another year of meaningful margin improvement. It will include progress in MA. I think that reflects our disciplined approach to the plan design and footprint. We have repricing opportunities in group with, I think, about half the book repricing as of January.

Sure. Thanks. Look, when we entered this year from the Aetna perspective and all of CVS together, we're focused on a couple of objectives. One is to return the business to target margins; second, to regain leadership position overall in the industry. And within those objectives, we rallied around 3 very specific priorities: to be exceptional to fundamentals, make sure that we are distinctive, and we could offer distinct capabilities to our customers and build a really strong culture with top talent. And so we've been executing with discipline and rigor and urgency around those 3 priorities. And as you can see by the performance, and as Brian highlighted and David in his opening remarks, the plan is working. We are really encouraged by the progress across all of our businesses at Aetna, and we believe this momentum will carry into not only the fourth quarter but also 2026. We plan to capitalize on that momentum. That said, we are mindful of the high trend environment as we are in the first year of a multiyear recovery. We are particularly pleased with the advancements we've made. Regarding Medicare and open enrollment, it's still early, but things are proceeding according to our expectations aligned with our objectives to return to target margins for this business. We've made significant progress, and the trends in the individual Medicare Advantage business during the third quarter are favorable. We intend to build on that momentum, and early indicators show that we are on track to sustain this progress and achieve our target margin.

With respect to just sort of overall competitive positioning, we like our position. Again, early days. We do have the ability and we've developed capabilities as we did last year during the AEP to continue to make adjustments and be nimble as we need to dial up and down products, geographies, other kinds of mechanisms that we have just to make sure that we continue on track in a really disciplined and rational approach. So so far, so good. And I would just say, we expect to exit AEP roughly flat in our individual Medicare Advantage membership. So very encouraged so far, early signs. Look forward to providing more color at our Investor Day.

Yes. Great quarter, and congrats to you and your team. So this will conclude the earnings call for this quarter. So before I end the call, I just want to thank our dedicated colleagues across CVS Health for the work you do every day. The trust we earn comes directly from the commitment to caring for our customers. I'm very encouraged about the progress we continue to make and look forward to providing you additional updates at our Investor Day on December 9. Thank you for joining the call.