Exhibit 10.48


             FIFTH AMENDMENT TO EMPLOYMENT AGREEMENT BY AND BETWEEN
           NATIONAL MEDICAL HEALTH CARD SYSTEMS, INC. AND JAMES BIGL


     This Fourth  Amendment  dated August 5, 2003  ("Effective  Date") is by and
among National Medical Health Card Systems, Inc., (the "Company") and James Bigl
("Employee").  All defined terms used, but not otherwise  defined herein,  shall
have their meanings set forth in the Employment Agreement,  as amended,  between
Company and Employee  dated May 3, 2000 and amended July 18, 2001 and as further
amended on April 15, 2002,  October 14, 2002 and  November 6, 2002  respectively
(the "Amended Employment Agreement").

                                   WITNESSETH:

     WHEREAS,  the Company and Employee have entered into the Amended Employment
Agreement; and

     WHEREAS,  both the Company and the Employee  are desirous to amend  certain
provisions of the Amended Employment Agreement.

     NOW,  THEREFORE,  in  consideration  of the mutual  covenants  and promises
contained herein, the parties agree as follows:

     1. In addition to the existing provisions reflected in Paragraph 3.1 of the
Amended  Agreement,  Paragraph  3.1 shall be  amended  by  adjusting  Employee's
compensation  and  annual  bonus  pursuant  to the  resolutions  adopted  by the
Compensation Committee and Board of Directors of the Company at meetings held on
July 9, 2003 and August 5, 2003, respectively.

     2. From and after the date hereof,  Paragraph 3.4 of the Agreement shall be
deleted in its entirety, and substitute in lieu thereof:

               The  Company  shall  pay  the  Employee  the sum of  $10,000  per
          calendar  quarter  for  non-accountable  expenses  incurred  by him in
          connection with the performance of his duties or in furtherance of the
          business and/or interest of the Company.

     3. In addition to the Stock  Options  granted to Employee in Paragraph 4 of
the Amended  Agreement  and as further  approved by  Compensation  Committee and
Board of Directors of the Company at meetings held on July 9, 2003, the Employee
will be granted by the  Company an option to  purchase  50,000  shares of Common
Stock of the Company, effective July 22, 2003, in accordance with the terms of a
Stock Option Agreement attached hereto as Exhibit A.

     4. Except as expressly  provided  herein,  all terms and  conditions of the
Amended Agreement shall be unmodified and in full force and effect.

     5.  From and  after the  execution  and  delivery  of this  Amendment,  all
references  to  the  Amended   Agreement   contained  in  other  agreements  and
instruments  executed  and  delivered  pursuant  to or in  connection  with  the
Agreement shall  hereinafter mean and refer to the Amended  Agreement as amended
hereby.

     6. This Amendment may be executed in  counterparts  by the parties  hereto,
all of  which  shall  constitute  one  and  the  same  instrument.  A  facsimile
transmission of this signed  amendment  bearing a signature on behalf of a party
hereto shall be binding on such party.


     IN WITNESS  WHEREOF,  the Company and Employee  have  executed  this Second
Amendment the day and year first above written.

                                  NATIONAL MEDICAL HEALTH CARD
                                  SYSTEMS, INC.
                                  By:

                                  ______________________________________
                                  Bert E. Brodsky, Chairman of the Board


                                  ______________________________________
                                  James Bigl