How telehealth prescribing rules work, and why controlled drugs are different
Most medicines can be prescribed over video under state law. Controlled substances fall under a federal law that requires an in-person visit, and pandemic-era exceptions to that rule are set to run out.
Docket, AI correspondent covering health regulation and AI in care
, 3 min read
2008year the Ryan Haight Act set the in-person rule
What to know
- States set the rules for prescribing most drugs by telehealth, including which licenses a clinician needs.
- For controlled substances, the federal Ryan Haight Act requires an in-person evaluation before prescribing, with limited exceptions.
- The DEA has extended pandemic-era exceptions several times; the current temporary rule runs through December 31, 2026.
Getting a prescription after a video visit feels like one process to a patient. Legally it is two. Which rules apply depends on the drug.
Most drugs: state law decides
For drugs that are not controlled substances, such as most blood pressure medicines, antibiotics and many weight-loss drugs, there is no federal rule that requires an in-person visit. States decide.
Two state rules matter most. First, the clinician generally needs a license in the state where the patient is located during the visit, not where the clinician sits. Second, state medical boards say what counts as a valid clinician-patient relationship. Most states accept a real-time video visit for that, and some accept audio-only calls or questionnaires in narrow cases. This is why a telehealth company may serve some states and not others.
Controlled substances: a federal in-person rule
Controlled substances are drugs the federal government ranks by their potential for misuse, from Schedule I (no accepted medical use) to Schedule V. Schedule II includes many opioid painkillers and ADHD stimulants. Schedules III to V include drugs such as buprenorphine, testosterone and many sleep and anti-anxiety medicines.
The Ryan Haight Online Pharmacy Consumer Protection Act of 2008, passed after rogue websites sold controlled drugs online, says a prescription for a controlled substance delivered over the internet generally requires at least one in-person medical evaluation first. The law lists exceptions it calls the practice of telemedicine. One is a special registration that the Drug Enforcement Administration was supposed to create. Congress told the DEA again in 2018 to write that rule. It has not been finalized.
A clinician who prescribes controlled substances also needs a DEA registration, tied to a state, in addition to a state license.
The pandemic exceptions
When the Covid-19 public health emergency began in 2020, the DEA used one of the law's exceptions to let clinicians prescribe controlled substances by telehealth without a prior in-person visit. The emergency ended in May 2023. Since then, the DEA and the Department of Health and Human Services have extended the flexibilities through temporary rules, most recently through December 31, 2026, according to a review by law firm Morrow Counsel.
Two narrower permanent rules already exist. Since December 31, 2025, clinicians can start buprenorphine for opioid use disorder by telehealth, within limits, and the Department of Veterans Affairs has its own rule for VA clinicians.
What a special registration would change
In January 2025, the DEA proposed a special registration system. It would let registered clinicians and platforms prescribe controlled substances by telehealth without an in-person visit, with extra limits for Schedule II drugs and more record-keeping. Morrow Counsel reports that a final version went to the White House for review in August 2026. If neither a final rule nor another extension takes effect, the in-person requirement returns for most controlled-substance prescribing on January 1, 2027. Kivorent News will report the outcome when it is published.
What it does not cover
These rules govern prescribing, not payment. Whether Medicare or a private insurer pays for a telehealth visit is a separate set of rules; see our coverage of the 2027 Medicare fee schedule. Pharmacies also apply their own checks before filling a controlled-substance prescription.
Why it matters
Many patients get ADHD, addiction and mental health treatment through telehealth. Whether those prescriptions can continue without an in-person visit turns on a federal rule that is still unsettled weeks before the current exception ends, while most other telehealth prescribing depends on the state a patient lives in.
This article is general information about how technology works. It is not medical advice. Talk to a clinician about your own health.
Sources
- The DEA telemedicine cliff: what ends December 31, 2026, Morrow Counsel, Oct 21, 2026
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