Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved Creating a Sustainable Pharmacy Benefit January 15, 2015 Steve Miller, MD Chief Medical Officer

2 © 2014 Express Scripts Holding Company. All Rights Reserved. 2 National Drug Trend 2.4% 14.1% 5.4% Traditional Specialty Overall 1% TREND INCREASE COSTS THE U.S. $2.5 BILLION Source: Express Scripts book of business

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved Specialty Spending Growth Continues © 2014 Express Scripts Holding Company. All Rights Reserved Traditional Specialty

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved More Than 5,400 Drugs in Development

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved FDA New Drug Approvals Source: U.S. Food and Drug Administration

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved Price InflationHigher Utilization N EVER BEFORE HAVE WE SEEN SUCH HIGH PRICES ON MEDICATIONS THAT ARE USED BY SO MANY May 2014 Why Is Trend Increasing?

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved PREVALENCE5.4 million14 million71 million3.2 million ANNUAL COST$35,000>$100,000$10,000~$100,000 CancerHigh CholesterolHepatitis CAlzheimer’s Costly, High Use Drugs On the Horizon

8 © 2014 Express Scripts Holding Company. All Rights Reserved. Building Cost Control Benefit Design Utilization Management Clinical Pathways Clinical Care Formulary

9 © 2014 Express Scripts Holding Company. All Rights Reserved. Formulary Exclusions Endocrine Disorders growth hormones Multiple Sclerosis interferon beta Hepatitis protease inhibitors pegylated interferons other direct-acting antivirals Blood Disorders erythropoiesis-stimulating agents Infertility ovulatory stimulants Inflammatory Conditions tumor necrosis factor antagonists Osteoarthritis hyaluronic acid derivatives

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 10 © 2014 Express Scripts Holding Company. All Rights Reserved. 10 © 2014 Express Scripts Holding Company. All Rights Reserved. 10 Benefit Design Tools CopaysMedical Benefit Management Networks

11 © 2014 Express Scripts Holding Company. All Rights Reserved. Utilization Management Drug Quantity LimitsStep TherapyPrior Authorization

12 © 2014 Express Scripts Holding Company. All Rights Reserved. Clinical Pathways Evidence-Based MedicinePhysician Partnerships

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 13 © 2014 Express Scripts Holding Company. All Rights Reserved. 13 © 2014 Express Scripts Holding Company. All Rights Reserved. 13 Clinical Pathways: Breast Cancer Study Comparing Cost of On- and Off-guideline Treatments NUMBER (%) PATIENTS OVERALL MEDICAL COST BREAST CANCER-RELATED MEDICAL COST OVERALL PHARMACY COST Off-Guideline265 (20%)$91,949$75,463$4,203 On-Guideline1,059 (80%)$82,446$67,504$4,145 Total (wt. avg)1,324 (100%)$84,348$69,097$4,156 Overall Costs includes breast cancer-related and non breast cancer-related costs. Medical Cost indicates claims billed through the medical benefit. Pharmacy Cost indicates claims billed through the outpatient pharmacy benefit. Express Scripts research, Aug Source: Thomson Reuters MarketScan® Commercial Claims and Encounters database; integrated pharmacy and medical claims Included continuously enrolled breast cancer patients (ICD xx, age 18-63) with index chemotherapy claim between July-Dec 2009; excluded patients. With non-breast cancer medical claims. $7,959 average medical benefit savings for each patient moved to On-Guideline care 8.64% reduction in total overall medical and pharmacy expenditure (weighted average) Study compares the cost of drugs and services between patients being treated On-Guideline and Off-Guideline National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology On-Guideline patients have lower breast cancer-related, overall medical and overall pharmacy costs

14 © 2014 Express Scripts Holding Company. All Rights Reserved. Clinical Care Specialist pharmacists offer: Unique Experience Specialized knowledge Behavioral expertise Focused familiarity Therapeutic Resource Centers SM 18% INCREASE IN ADHERENCE VS. RETAIL

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 15 © 2014 Express Scripts Holding Company. All Rights Reserved. 15 © 2014 Express Scripts Holding Company. All Rights Reserved. 15 Controlling Specialty Drug Costs Requires Active Management Network Open SpecialtyExclusive Specialty Step Therapy No programsOne or fewerMultiple programs BOB SPECIALTY TREND 18.4% Source: Express Scripts Research Study.

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 16 © 2014 Express Scripts Holding Company. All Rights Reserved. 16 © 2014 Express Scripts Holding Company. All Rights Reserved. 16 Adherence Is Survival for Transplant Patients Specialty Pharmacy Management Raises Adherence, Lowers Cost NONADHERENCE IS A FACTOR IN 36% OF TRANSPLANT LOSSES With 20% - 50% of transplant patients nonadherent 2 Accredo ® transplant patients have higher adherence than retail. Drive adherence. Save organs. Save lives. 1.Express Scripts research, Aug Source: Thomson Reuters MarketScan ® Commercial Claims and Encounters database. Bivariate correlation. Patients selected if had at least two pharmacy claims for immune suppression medications between 1/1/2007 and 12/31/ Laederach-Hofmann K, Bunzel B. Noncompliance in organ transplant recipients: a literature review. General Hospital Psychiatry. 2000;6:

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 17 © 2014 Express Scripts Holding Company. All Rights Reserved. 17 © 2014 Express Scripts Holding Company. All Rights Reserved. 17 Managing Overall Cost and Enhancing Quality of Care Results in… Better Clinical Care CareLogic and TRCs Specialty-trained pharmacists and nurses Complete medication and medical profile Comprehensive therapy management Proactive outreach to 100% of patients Teachable moments maximized BETTER ADHERENCE BETTER HEALTH OUTCOMES LOWER COSTS Pulmonary Arterial Hypertension 17% higher than retail 32% fewer hospitalizations 35% fewer ER visits $13,000 less medical expense per patient* Rheumatoid Arthritis 16% higher than retail 9% fewer hospitalizations 13% fewer ER visits 16% savings on medical expenses* Multiple Sclerosis 32% higher than retail 39% fewer hospitalizations 39% fewer ER visits 31% savings on medical expenses* *Annual

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 18 © 2014 Express Scripts Holding Company. All Rights Reserved. 18 © 2014 Express Scripts Holding Company. All Rights Reserved. 18 Specialty Adherence Solutions Application of novel devices to high-touch care model Suite of potential adherence devices under investigation DidIt ® Dose-Alerts ® GlowCaps Specialty Patients May Be Well-Suited for Adherence Aids Complex Regimens Neurological Conditions Significant Consequences of Non-adherence Leveraging Behavioral Research from Traditional PBM Applying Solutions to Specialty GlowPacks MedMinder™

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 19 © 2014 Express Scripts Holding Company. All Rights Reserved. 19 © 2014 Express Scripts Holding Company. All Rights Reserved. 19 Further Improving Oncology Results Pilot: Increase Contact, Identify Intolerance, Clinically Educate Pilot Intervention Persistence at One Month Decrease dispensing to 15-day supplies Increase member contact Assess need for additional education Verify patient tolerating medication regimen Source: Express Scripts client claims data 2010 and % PERSISTENCE LIFT Increased patient contact and clinical education through OncoScripts ® program REDUCED EARLY DROP-OFF RATE BY 11%

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 20 © 2014 Express Scripts Holding Company. All Rights Reserved. 20 © 2014 Express Scripts Holding Company. All Rights Reserved. 20 Clinical Days’ Supply Improving Therapy Adherence and Health Outcomes Utilizes evidence-based clinical guidelines Considers clinical and financial appropriateness Increases therapy adherence Improves health outcomes Patient Average Adherence Accredo ® internal analysis of unblocked CDS clients versus 30 Days’ Supply only clients, November PDC adherence methodology= proportion of days covered 180-day fixed interval. See: Yeaw J, et al. Comparing Adherence and Persistence Across 6 Chronic Medication Classes. JMCP 2009; 15(9): Sokol MC, McGuigan KA, Verbrugge RR, et al. Impact of Medication on Hospitalization Risk and Healthcare Cost. Medical Care. 2005;43: Studies show increased adherence leads to better clinical and humanistic outcomes for the patient and reduces medical spend for the client.

21 Biosimilars

22 Projected Savings Projected Sales: No Biosimilars Projected Sales: With Biosimilars $250 BILLION THROUGH 2024

23 FDA Accepts 1 st Biosimilar

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 24 © 2014 Express Scripts Holding Company. All Rights Reserved. 24 © 2014 Express Scripts Holding Company. All Rights Reserved. 24 Price Shock Not Felt Round the World $94,500 Harvoni

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 25 © 2014 Express Scripts Holding Company. All Rights Reserved. 25 © 2014 Express Scripts Holding Company. All Rights Reserved. 25 Sovaldi Cost Ignites Payers & Patients

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 26 © 2014 Express Scripts Holding Company. All Rights Reserved. 26 © 2014 Express Scripts Holding Company. All Rights Reserved. 26 Sparking a Necessary Debate

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 27 © 2014 Express Scripts Holding Company. All Rights Reserved. 27 © 2014 Express Scripts Holding Company. All Rights Reserved. 27 Savings in India: $75,000+

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 28 © 2014 Express Scripts Holding Company. All Rights Reserved. 28 © 2014 Express Scripts Holding Company. All Rights Reserved. 28 Savings in Egypt: $80,000+

29 © 2014 Express Scripts Holding Company. All Rights Reserved. 29 Pharmaceutical Companies S UPPORT BIOSIMILARS S HOW BETTER JUDGMENT IN PRICING R EDUCE INTERNATIONAL PRICE DISPARITIES R EFORM PATENT SYSTEM

30 © 2014 Express Scripts Holding Company. All Rights Reserved. 30 © 2014 Express Scripts Holding Company. All Rights Reserved. 30 Federal Government B RING COST INTO CARE EQUATION B OOST NIH RESEARCH B ETTER FUND FDA A DJUST MALPRACTICE LAWS

31 © 2014 Express Scripts Holding Company. All Rights Reserved. 31 © 2014 Express Scripts Holding Company. All Rights Reserved. 31 Payers A DVOCATE FOR FAIR PRICING U SE BENEFIT DESIGN & CLINICAL CARE TO ENSURE QUALITY AND COST CONTAINMENT W ORK TOGETHER FOR COMMON CAUSE

Confidential and Proprietary Information © 2014 Express Scripts Holding Company. All Rights Reserved. 32 © 2014 Express Scripts Holding Company. All Rights Reserved. 32 © 2014 Express Scripts Holding Company. All Rights Reserved. 32 Summary Exorbitant drug pricing threatens the pharmacy benefit 1 Specialty trend is an ongoing and growing challenge 2 Managing specialty spend requires a range of existing tools 3 Providing affordable, high-quality care means rebalancing innovation, policy and pharma ROI 4