Request for Loratadine Replacement

Dear Sir or Madam:

I have tried over-the-counter 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 (choose one)

       Allegra    Zyrtec       Clarinex

as a prescription benefit under my insurance plan.

Sincerely,

Name
Insurance Company
ID#