In the fourth quarter, we recorded an after-tax special item charge of $119 million or $0.36 per share related to a strategic plan to further leverage the company's ongoing growth to drive operational efficiency through enhancements to organizational structure and increased use of automation and shared services.
We also recorded an after-tax special item charge of $70 million or $0.21 per share for integration and transaction-related costs.
As a result, our 70,000-plus colleagues around the world continue to deliver differentiated value for those we serve and also continue to grow our businesses.
In 2021, we grew full-year adjusted revenues to $174 billion, a second consecutive year of growth above our long-term target.
We delivered full-year adjusted earnings-per-share growth of 11% and to $20.47, and we returned over $9 billion to shareholders in dividends and share repurchases.
We grew adjusted revenues by 14% in 2021 as Evernorth's corporate clients, health plans, governmental agencies, and healthcare delivery system partners increasingly recognized the value of our health services, including in our specialty pharmacy business, which I'll discuss in more detail in just a moment; in our virtual health capabilities, which have been expanded through MDLIVE to include urgent and dermatology care as well as behavioral health services; in our core pharmacy services portfolio, which continues to generate outstanding results for our clients; and we are further broadening our reach through deeper and new partnerships.
As a result, our medical care ratio for Cigna Healthcare was 84% for full year 2021.
As I highlighted earlier, the breadth and complementary nature of our portfolio enabled us to exceed our revenue and earnings per share outlook and return over $9 billion of capital to our shareholders.
By 2025, for example, 66 biologic drugs currently in the market will have the patents expire, opening the door for increased biosimilar competition and an increasing opportunity to decrease healthcare spending by an estimated $100 billion.
For 2022, we entered three new states and 93 new counties.
With these markets, for example, we have the ability to reach an additional 1.5 million additional customers.
Our earnings per share outlook of at least $22.40 and the increase of our quarterly dividend by 12% reinforces the sustained growth and strength of our businesses.
We delivered adjusted earnings per share of $20.47 and returned over $9 billion of capital to our shareholders in dividends and share repurchase.
Key consolidated financial highlights for full year 2021 include adjusted revenue growth of 9% to $174 billion or growth of 12% when adjusting for the sale of the group disability and life business.
Adjusted earnings of $7 billion after tax and adjusted earnings-per-share growth of 11% to $20.47.
Fourth quarter 2021 adjusted revenues grew 15% to $35.1 billion, while adjusted pre-tax earnings grew to $1.6 billion.
Overall, fourth-quarter adjusted revenues were $11.2 billion, adjusted pre-tax earnings were $472 million and the medical care ratio was 87%.
For full year 2021, we finished with the medical care ratio of 84%.
We ended the year with 17.1 million total medical customers, an increase of approximately 430,000 customers for the full year.
The fourth-quarter adjusted loss was $115 million and now includes positive earnings contributions from our international life accident and supplemental benefits businesses held-for-sale pending divestiture.
As Ralph noted, during the fourth quarter, we reported a special item charge of $119 million after tax related to actions to improve our organizational efficiency.
In total for the company, we expect consolidated adjusted revenues of at least $177 billion, representing growth of approximately 4%, excluding the impact from previously announced divestitures.
We expect full-year consolidated adjusted income from operations to be at least $6.95 billion or at least $22.40 per share, consistent with our prior earnings per share commentary.
We project an expense ratio in the range of 6.9% to 7.3%, further improving upon our operational efficiency and ensuring continued affordable solutions for our clients and customers.
And we expect a consolidated adjusted tax rate in the range of 22% to 22.5%.
For Evernorth, we expect full year 2022 adjusted earnings of approximately $6.1 billion.
This represents growth of about 5% over 2021, within our targeted long-term income growth range, reflecting strong growth in Accredo specialty pharmacy, all while we continue to increase investments in order to drive new innovative solutions to the market.
For Cigna Healthcare, we expect full year 2022 adjusted earnings of approximately $3.9 billion.
We expect the 2022 medical care ratio to be in the range of 82% to 83.5%.
This action has contributed to results within our commercial book of business, where we are now seeing fewer than 20% of all knee and hip replacements occur in an inpatient hospital setting, down from over 75% in 2019.
In 2021, we finished the year with $7.2 billion of cash flow from operations.
Additionally, we returned over $9 billion to shareholders via dividends and share repurchase in 2021, a significant increase from 2020.
We expect at least $8.25 billion of cash flow from operations, up more than $1 billion from 2021, reflecting the strong capital efficiency of our well-performing business.
We expect to deploy approximately $1.25 billion to capital expenditures, an increase from our 2021 capex levels.
We expect to deploy approximately $1.4 billion to shareholder dividends, reflecting our meaningful quarterly dividend of $1.12 per share, a 12% increase on a per-share basis.
Our guidance assumes full year 2022 weighted average shares to be in the range of 308 million to 312 million shares.
Year to date, as of February 2, 2022, we have repurchased 2.5 million shares for $581 million.
We are confident in our ability to deliver our 2022 full-year adjusted earnings of at least $22.40 per share, consistent with our prior earnings per share commentary.

Summary:
In the fourth quarter, we recorded an after-tax special item charge of $119 million or $0.36 per share related to a strategic plan to further leverage the company's ongoing growth to drive operational efficiency through enhancements to organizational structure and increased use of automation and shared services.
In total for the company, we expect consolidated adjusted revenues of at least $177 billion, representing growth of approximately 4%, excluding the impact from previously announced divestitures.
We expect full-year consolidated adjusted income from operations to be at least $6.95 billion or at least $22.40 per share, consistent with our prior earnings per share commentary.
We expect the 2022 medical care ratio to be in the range of 82% to 83.5%.
We expect to deploy approximately $1.4 billion to shareholder dividends, reflecting our meaningful quarterly dividend of $1.12 per share, a 12% increase on a per-share basis.