National Medical Health Card Systems, Inc. 26 Harbor Park Drive Port Washington, NY 11050 Phone 516/484-4400 Fax 516/484-3290 March 30, 1999 Vytra Health Plans Long Island, Inc. 395 N. Service Road Melville, NY 11747 Reference is made to that certain...

                   National Medical Health Card Systems, Inc.
                              00 Xxxxxx Xxxx Xxxxx
                            Xxxx Xxxxxxxxxx, XX 00000
                               Phone 516/000-0000
                                Fax 516/000-0000




March 30, 1999

Vytra Health Plans Long Island, Inc.
000 X. Xxxxxxx Xxxx
Xxxxxxxx, XX 00000

                  Reference  is made  to that  certain  letter  agreement  dated
September  25, 1998 between  Vytra  Health Plans Long Island,  Inc. and National
Medical  Health  Card  Systems,  Inc.  (the  "Letter  Agreement").  Each  of the
undersigned   hereby  agrees  that  the  Letter   Agreement   shall  govern  the
relationship between the undersigned through December 31, 1999.

                  The parties  will  continue  the  process of  preparing a more
formal agreement.

                  Please  acknowledge your agreement to the foregoing by signing
a copy of this letter in the space provided below.

                                    Yours truly,

                                    NATIONAL MEDICAL HEALTH CARD IPA, INC.


                                    By:/s/ Xxxx X. Xxxxxxx          
                                       ------------------------
                                       Xxxx X. Xxxxxxx

Acknowledged and Agreed:

VYTRA HEALTH PLANS LONG ISLAND, INC.

By:/s/ Xxxxxx Xxxxxxxx                
   --------------------- 
   Xxxxxx Xxxxxxxx

NATIONAL MEDICAL HEALTH CARD SYSTEMS, INC.

By:/s/ Xxxx X. Xxxxxxx                
   ---------------------
   Xxxx X. Xxxxxxx