FAX TO: 212-935-0092

Dear Sir or Madame:

I have tried over-the-counter generic loratadine for two weeks to treat my allergic problems.
I don't find that it is a suitable drug for me and I request that it be authorized for me to have
(Allegra/Zyrtec/Clarinex) as a prescription benefit under my insurance plan.

Sincerely,

Name____________________________________________

Insurance Company_________________________________

ID #_____________________________________________

Date________________________

Signature_________________________________________