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Allonge to Replacement Promissory Note - The Bank of New York and Mid Atlantic Medical Services Inc.

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                     ALLONGE TO REPLACEMENT PROMISSORY NOTE

     This  Allonge  made this 6th day of  September,  2002,  to the  Replacement
Promissory Note dated December 20, 1996, as amended by Allonge dated January 11,
1999,  Allonge dated August 20, 1999,  Allonge dated August 4, 2000, and Allonge
dated July 11,  2001,  made by The Bank of New York,  not in its  individual  or
corporate  capacity,  but solely in its  capacity as Trustee of the Mid Atlantic
Medical Services,  Inc. Stock  Compensation  Trust  ("Borrower") in favor of Mid
Atlantic Medical Services, Inc. ("Lender").

     WHEREAS, Borrower executed and delivered to Lender a Replacement Promissory
Note dated December 20, 1996 in the original  principal  amount of  $129,902,500
(the "Original Note").

     WHEREAS,  the Original Note was most recently amended by an Allonge on July
11, 2001.

     WHEREAS,  under  the terms of such  Allonge,  the  principal  amount of the
Original   Note  due  and  owing  as  of  July  11,   2001  was   increased   to
$145,594,696.75.

     WHEREAS,  $91,692,572.75  of the principal  amount of the Original Note, as
amended by such  Allonge  (the  "Amended  Note")  remains  unpaid as of the date
hereof.

     WHEREAS, in order to finance the Borrower's purchase of 2,000,000 shares of
the  Lender's  common  stock  pursuant  to the  terms of Common  Stock  Purchase
Agreement of even date  herewith  between the Borrower and Lender,  Borrower and
Lender wish to increase the  principal  amount of the Amended Note due and owing
from  $91,692,572.75  to  $161,572,572.75  while  leaving all other terms of the
Amended Note unamended.

     NOW,  THEREFORE,  for good and valuable  consideration  and intending to be
legally bound hereby, the parties hereto agree as follows:

          (1) The Amended Note is hereby  amended by deleting all  references to
     "$145,594,696.75" and by inserting in lieu thereof "$161,572,572.75."

          (2) The last  sentence of the second  paragraph of the Amended Note is
     hereby  amended by deleting  the date "July 11,  2001" and by  inserting in
     lieu thereof "September 6, 2002."

          (3)  Schedule A attached  to the  Amended  Note is hereby  amended and
     restated in its entirety in the form attached hereto as Exhibit 1.

          (4)  Schedule B attached  to the  Amended  Note is hereby  amended and
     restated in its entirety in the form attached hereto as Exhibit 2.

          (5) Except as expressly amended hereby,  the Amended Note shall remain
     unamended and in full force and effect.



                  [REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]



<PAGE>


     IN  WITNESS  WHEREOF,  this  Allonge  to  Replacement  Promissory  is  made
effective as of the 6th day of September, 2002.


Attest:                             THE BANK OF NEW YORK, not in its individual
                                    or corporate capacity, but solely in its
                                    capacity as Trustee of the Mid Atlantic
                                    Medical Services, Inc. Stock Compensation
                                    Trust
By:  /s/  Thomas Macioce            By:  /s/ Lorraine Serio
______________________________           ______________________________
                                             Lorraine Serio
                                    Title:   Vice President


Attest:                             MID ATLANTIC MEDICAL SERVICES, INC.

______________________________      By:  /s/ Robert E. Foss
                                         ______________________________
                                             Robert E. Foss
                                    Title:   Senior Executive Vice President
                                             and Chief Financial Officer



<PAGE>


                                   Exhibit 1

<TABLE>
<CAPTION>
Trust Year                      Amount
<S>                            <C>

         2002                   8,500,000
         2003                  17,000,000
         2004                  17,000,000
         2005                  17,000,000
         2006                  17,000,000
         2007                  17,000,000
         2008                  17,000,000
         2009                  17,000,000
         2010                  17,000,000
         2011                  17,072,573

</TABLE>



<PAGE>


                         MAMSI Stock Compensation Trust

                                    Exhibit 2
<TABLE>
<CAPTION>

  Interest
  Pay Date       Year         Amount
-----------------------------------------
<S>             <C>           <C>
    10/15            2002      2,485,034
    1/15             2003      3,148,340
    4/15                       3,061,451
    7/15                       2,978,340
    10/15                      2,891,451
    1/15             2004      2,808,340
    4/15                       2,721,451
    7/15                       2,638,340
    10/15                      2,551,451
    1/15             2005      2,468,340
    4/15                       2,381,451
    7/15                       2,298,340
    10/15                      2,211,451
    1/15             2006      2,128,340
    4/15                       2,041,451
    7/15                       1,958,340
    10/15                      1,871,451
    1/15             2007      1,788,340
    4/15                       1,701,451
    7/15                       1,618,340
    10/15                      1,531,451
    1/15             2008      1,448,340
    4/15                       1,361,451
    7/15                       1,278,340
    10/15                      1,191,451
    1/15             2009      1,108,340
    4/15                       1,021,451
    7/15                         938,340
    10/15                        851,451
    1/15             2010        768,340
    4/15                         681,451
    7/15                         598,340
    10/15                        511,451
    1/15             2011        428,340
    4/15                         341,451
    7/15                         258,340
    8/26                          78,106
                          ---------------
                              62,147,927
                          ===============
</TABLE>