Navigating Telemedicine Prescribing Rules for 2026 Changes

By Elena Pak, Credentialing Department, WCH

A pandemic-era flexibility expires December 31. A permanent replacement is under federal review, but its final text is not yet public. Here is where the rules stand — and what providers should be watching.

Picture a psychiatrist with a full telehealth panel. Many of her patients live hours from the nearest clinic. A good number take medications that fall under federal controlled-substance rules. Right now, she can prescribe them after a video visit, with no in-person appointment first.

On January 1, she may not be able to. Or she may. Or her state may have its own answer. That’s the honest state of play as of early October 2026, and it’s why this topic keeps landing in our inbox.

The short version

Through December 31, 2026, a DEA-registered practitioner can prescribe Schedule II–V controlled substances by telemedicine without a prior in-person evaluation. For most controlled substances, the encounter must be conducted by audio-video.
This is temporary. It is the fourth extension of pandemic-era telemedicine prescribing flexibilities.
A permanent rule is under White House review. The DEA submitted its final special-registration rule to OIRA on August 25. The final text is not public.
State law still applies. The federal flexibility does not override stricter state requirements or replace state licensure.
Buprenorphine and VA patients have separate permanent telemedicine pathways already in place.

How We Got Here: A Promise From 2008

The story starts with the Ryan Haight Online Pharmacy Consumer Protection Act, passed in 2008 after a teenager died from drugs obtained online. The law generally requires a practitioner to conduct at least one in-person medical evaluation before prescribing a controlled substance over the internet. It carved out exceptions, including circumstances involving a patient located at a DEA-registered hospital or clinic and situations in which another practitioner is physically present during the evaluation.

It also directed the Attorney General to establish a special registration process for telemedicine that would allow qualified providers to prescribe without that first in-person visit. Congress returned to the issue in the 2018 SUPPORT for Patients and Communities Act, which gave the agency a one-year deadline. The DEA did not issue the regulation by October 2019.

Then came COVID-19. The DEA used its authority under the Controlled Substances Act to allow registered practitioners to prescribe controlled substances after a real-time audio-video telemedicine encounter. When the federal public health emergency ended in May 2023, the DEA and HHS continued the telemedicine flexibilities through a series of temporary extensions while working toward permanent regulations.

The third extension ran through December 31, 2025. The fourth runs through December 31, 2026.

Seven years after the original deadline, the agency is still working on the permanent version.

What’s Allowed Right Now

Under the current temporary rules, a DEA-registered practitioner can prescribe Schedule II–V controlled substances to a patient who has never had an in-person evaluation with that practitioner. A few conditions matter.

Audio-video is the default. For most controlled substances, the encounter must use a real-time, two-way audio-video system. A separate audio-only authority applies to certain Schedule III–V narcotic medications approved by the FDA for the treatment of opioid use disorder.

The flexibility isn’t a blank check. The prescription must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice. The practitioner must have the appropriate DEA authority for the medication being prescribed. State licensing, prescribing, scope-of-practice, and controlled-substance requirements continue to apply.

If the practitioner has already conducted an in-person evaluation of the patient, the Ryan Haight in-person evaluation requirement does not continue to apply to subsequent telemedicine prescribing by that practitioner. Other federal and state requirements still apply.

The Part that Trips People Up: federal permission isn’t state permission

The temporary rule provides an exception under the federal Ryan Haight framework. It does not preempt states from imposing stricter requirements. State rules can vary by medication, provider type, and the nature of the patient-provider relationship.

Then there’s the two-key problem. When provider and patient are in different states, two separate requirements are in play, and people regularly confuse them:

	State licensure	DEA registration
Who sets it	Each state	Federal government (DEA)
General rule	A provider generally must be licensed or otherwise authorized in the state where the patient is located	A practitioner prescribing to a patient in another state generally needs DEA registration in that state
Exceptions	Some states offer exceptions, telehealth registrations, or interstate compact pathways	See the DEA’s Telemedicine Registration FAQ and Registration Q&A

Having one does not give you the other. A provider with a valid DEA registration in their home state and a license only in that state may be missing pieces if the patient is somewhere else.

A real-world example. A patient who lives in State A is on vacation in State B and wants a video visit with an established provider who is licensed only in State A. Can the provider treat them?

The answer many people expect is yes, because the patient lives in State A or because the relationship predates the trip. That’s generally not the safe assumption. For telehealth purposes, the patient’s physical location at the time of the encounter can determine which state’s licensure requirements apply. The patient’s permanent address and the length of the provider-patient relationship do not, by themselves, resolve the question. The provider should check State B’s licensing requirements, including any applicable exception or telehealth pathway.

The Exception for Phone Calls: Buprenorphine

Audio-only prescribing has a permanent place in one part of this landscape. In January 2025, the DEA and HHS finalized the Expansion of Buprenorphine Treatment via Telemedicine Encounter rule. It allows qualified practitioners to initiate certain buprenorphine treatment through telemedicine, including audio-only encounters, without first conducting an in-person evaluation. Conditions apply, including reviewing the prescription drug monitoring program (PDMP) for the state where the patient is located.

The rule allows a practitioner to initiate buprenorphine treatment through audio-only or audio-video telemedicine and prescribe up to a total six-month supply under the rule’s requirements. The six-month amount can be divided among multiple prescriptions. This permanent pathway is separate from the broader temporary telemedicine flexibility, which remains in effect through the end of 2026.

The VA Has Its Own Permanent Rule

A second final rule from January 2025, Continuity of Care via Telemedicine for Veterans Affairs Patients, covers the Department of Veterans Affairs.

Under the rule, a VA practitioner may prescribe Schedule II–V controlled substances by telemedicine when the required in-person evaluation was performed by another VA practitioner and the other conditions of the rule are met.

Both rules were designed to remain in place after the nationwide temporary flexibilities eventually end. For the vast majority of providers, though, neither one applies.

The Big Unresolved Piece: Special Registration

This is the piece that matters most. In January 2025, the DEA proposed Special Registrations for Telemedicine and Limited State Telemedicine Registrations. The proposal would allow certain practitioners to prescribe controlled substances by telemedicine without a prior in-person evaluation, subject to additional safeguards, registration, recordkeeping, reporting, and other conditions. It also proposed requirements for certain direct-to-consumer telemedicine platforms involved in controlled-substance prescribing.

The response was substantial. The DEA reported more than 6,475 comments and widespread stakeholder concern. Rather than immediately finalize the proposal, the agency extended the pandemic-era flexibilities again. Now the picture is shifting.

The DEA submitted a final telemedicine special-registration rule to OIRA on August 25, 2026. The rule remained under review as of early October, and its final text was not publicly available. The final publication date remains uncertain.

The practical takeaway is that federal changes to telehealth controlled-substance prescribing are likely to be announced before the temporary authority expires on December 31. How much notice providers receive before new requirements take effect is still an open question.

What’s at Stake, and What Nobody Knows

The details of the final rule are not public, and they could significantly shape how controlled substances can be prescribed through telemedicine after the temporary flexibility ends. Three issues deserve particular attention.

Who qualifies. The 2025 proposal raised questions about which types of practitioners would be eligible to use the special-registration pathway for certain controlled substances. For primary care practices and patients who rely on telehealth for conditions such as ADHD, the final list of eligible practitioners could be particularly important.

How workable it is. The American Telemedicine Association has said it will push for a final framework that is permanent and workable in the real world, with fewer unnecessary in-person mandates, no duplicative state-by-state registrations, lighter reporting burdens, and realistic implementation timelines.

How much time providers get. In the December 2025 extension, the DEA said the additional year was intended to give the agency time to finalize regulations and give providers time to comply with any new registration, recordkeeping, or security requirements. If a final rule arrives late in 2026, that implementation window could be limited.

What Providers Should Be Preparing For

If the final rule arrives with enough lead time: Providers may have time to obtain any required registrations, update workflows and documentation, and bring telehealth systems into compliance.

If the final rule arrives close to December 31: The biggest challenge may be implementation. Practices and telehealth platforms could face new requirements without much time to adjust.

If the temporary flexibilities are extended again: Providers get more breathing room, but the underlying uncertainty remains.

There is also a more serious possibility. If the temporary flexibilities expire without a final rule or another extension, patients who rely on telemedicine for controlled-substance treatment could face disruptions in access to care.

What to Do Between Now and December 31

If you’re a prescriber:

Keep operating under the current federal rules. They remain in force through December 31, 2026.
Check your state’s requirements for prescribing controlled substances through telemedicine.
For every patient in another state, confirm both your licensure pathway and your DEA registration requirements there.
Don’t redesign your practice around the 2025 proposal. Until the final rule is published, important details can change.

If you run a health system or telehealth platform:

Audit which services depend on prescribing controlled substances without an in-person visit.
Map your patients’ locations against your clinicians’ state licensure and DEA registration requirements.
Prepare contingency plans for a late final rule, including a short implementation timeline.
Watch for requirements that may apply specifically to direct-to-consumer telemedicine platforms.

If you’re a patient or advocate:

Ask your provider how they are preparing for the end of the year.
If treatment involves buprenorphine, ask whether the permanent telemedicine pathway applies to your care.

Frequently asked questions

Is the telehealth prescribing flexibility ending right now?
No. The current federal flexibility remains in effect through December 31, 2026.
Can I prescribe controlled substances by phone?
For most controlled substances, the encounter must be conducted by audio-video. A separate permanent audio-only authority applies to certain Schedule III–V narcotic medications approved by the FDA for the treatment of opioid use disorder.
Does the federal flexibility override my state’s rules?
No. States can impose additional requirements, and providers must comply with applicable state and federal rules.
Do I need a DEA registration in the patient’s state?
As a general matter, a practitioner prescribing a controlled substance to a patient in another state must be registered with the DEA in that state, subject to applicable federal rules and exceptions.
When will the special-registration rule be final?
The exact date is unknown. The DEA submitted the final rule to OIRA on August 25, 2026, and it remained under review as of early October. The final publication date has not been established.

What We’re Watching

The DEA is now moving toward a permanent framework rather than relying indefinitely on broad temporary extensions. The final special-registration rule will determine how much of the current telemedicine model survives, what additional safeguards providers will face, and how quickly practices will have to adapt.

For now, the most important date is still December 31, 2026.

Until the final rule is published, providers should treat the current federal flexibility as exactly what it is: temporary. The safest strategy is to keep current workflows compliant, monitor state requirements, and be ready to adjust once the final federal requirements are public.

Sources

CCHP, TA Spotlight newsletter — history of the Ryan Haight Act, state licensure, buprenorphine, VA rule, and stakeholder comments
U.S. Drug Enforcement Administration — telemedicine prescribing flexibilities and January 2025 telemedicine rules
U.S. Office of Management and Budget, OIRA — status of the DEA special-registration final rule
McDermott Will & Emery — analysis of the DEA’s telemedicine special-registration rule
Alliance for Connected Care — analysis of the expiration of the current telemedicine flexibilities
National Association of State Controlled Substance Authorities (NASCSA) — telemedicine special-registration developments
Healthcare IT News — American Telemedicine Association position on the proposed framework
ADDRC — analysis of practitioner eligibility concerns raised by the proposed rule