MINNETONKA, Minn. (AP) — UnitedHealth Group boosted its full-year outlook for a second time this year after a surprisingly strong second quarter despite sustained, elevated spending tied to the pandemic.

The country's largest U.S. health insurer earned $4.27 billion, or $4.46 per share. Adjusted for one-time gains and costs, per-share earning were $4.70, far better than the $4.41 that Wall Street had been projecting, according to a survey of industry analysts by Zacks Investment Research.

It's still below the $6.64 billion, or $6.91 per share, the company earned in the same three-month period last year, which ended June 30. Those three months were an extraordinary stretch with so many people calling off visits to the doctor's office, elective surgery, and other non-emergency visits due the pandemic.

The return of those patients after a successful vaccination program in the U.S. has added more medical costs for insurers like UnitedHealth. Executives with the Minnetonka, Minnesota, company said they expect to feel most of that impact during the second half of this year.

Quarterly revenue reached $71.32 billion, topping the $69.22 billion that Wall Street was calling for, thanks in part to double-digit percentage growth at Optum and UnitedHealthcare.

UnitedHealth now foresees full-year adjusted earnings in a range of $18.30 to $18.80 per share. In April the company raised its forecast to $18.10 to $18.60 per share, up from an outlook of $17.75 to $18.25 per share that it debuted in December.

The guidance accounts for approximately $1.80 per share in potential net unfavorable COVID-19 costs.

Analysts polled by FactSet predict full-year earnings of $18.57 per share.

Shares of UnitedHealth Group Inc. are flat before the opening bell Thursday.

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Elements of this story were generated by Automated Insights (http://automatedinsights.com/ap) using data from Zacks Investment Research. Access a Zacks stock report on UNH at https://www.zacks.com/ap/UNH