On December 31, 2026, the fourth temporary extension of COVID-era DEA telemedicine prescribing flexibilities expires. Under these flexibilities, DEA-registered physicians can prescribe Schedule II through V controlled substances via audio-video telehealth without a prior in-person visit. If the extension lapses without a replacement — either a fifth extension or a finalized permanent rule — the Ryan Haight Act's in-person requirement reinstates immediately.
What the Ryan Haight Act requires without the extension
The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 generally prohibits prescribing controlled substances via the internet unless the practitioner has conducted at least one in-person medical evaluation of the patient. Without the DEA extension, this requirement applies to telehealth prescribing. Physicians who have been prescribing controlled substances to telehealth patients without a prior in-person visit would need to either conduct an in-person visit or transfer care before January 1, 2027.
What is the proposed permanent rule?
The DEA proposed a permanent rule — Special Registrations for Telemedicine — in January 2025. It would create three pathways: a practitioner special registration, a platform registration, and a limited state telemedicine registration. The rule received over 6,000 public comments. As of July 2026, it has not been finalized. The direction of the current administration on this rule is unclear.
If December 31 passes without a fifth extension or a finalized permanent rule, the Ryan Haight in-person requirement reinstates immediately.
What physicians should do now
Review your patient panel for patients receiving controlled substances exclusively via telehealth, without any prior in-person evaluation. For each, consider whether an in-person visit before December 31 is feasible, whether the patient can be transferred to an in-person practice, or whether an audio-only exception applies (buprenorphine for OUD only, under the current extension). Do not wait until Q4 — in-person appointment availability tightens significantly toward year-end.
State-specific rules still apply
Even under the federal extension, some states impose stricter requirements. Florida prohibits Schedule II prescribing via telehealth except for hospice and nursing home patients. New York has issued its own final rule on telehealth CS prescribing that imposes additional in-person examination requirements for new patients. Always check state law alongside federal rules.