Telehealth prescribing after December 31, 2026: what behavioral health programs should prepare now

Where things stand

Since 2020, DEA-registered practitioners have been able to prescribe controlled substances by telemedicine without first seeing the patient in person. Those flexibilities have been extended four times. The current extension, published December 31, 2025, is effective through December 31, 2026.

While it lasts, a practitioner may prescribe Schedule II through V controlled substances by telemedicine without a prior in-person evaluation, as long as:

• the prescription is for a legitimate medical purpose in the usual course of professional practice;
• it follows communication through an interactive telecommunications system as defined in Medicare's telehealth rule (42 CFR 410.78(a)(3)), which allows audio-only in some cases;
• the practitioner's DEA registration covers that schedule (or the practitioner is exempt); and
• the prescription meets every other federal prescription requirement.

State law and payer contracts can be stricter than these federal rules, so check both.

The permanent rule is still in review

DEA proposed a permanent framework, Special Registrations for Telemedicine and Limited State Telemedicine Registrations, in January 2025. The final version was sent to the Office of Information and Regulatory Affairs (OIRA), the White House office that reviews significant rules, on August 25, 2026. OIRA has held a series of stakeholder meetings on it through October, with another scheduled for November 2. The federal regulatory agenda lists a target of November 2026 for the final rule, but that is a target, not a commitment.

As of October 29, 2026, the final rule had not been published, and its text is not public. That leaves three realistic outcomes for January 1:

1. The final rule is published before the flexibilities expire, with whatever effective date and transition it sets.
2. DEA and HHS issue a fifth temporary extension, as they have done four times before.
3. Neither happens, and the temporary flexibilities lapse. The federal in-person evaluation requirement (from the Ryan Haight Act) would again apply to most controlled-substance prescribing by telemedicine, including stimulants and benzodiazepines. Exceptions would be limited to the buprenorphine rule described below, a separate rule for Veterans Affairs patients, and the narrow telemedicine categories written into federal law.

Because the final text is unknown, don't rebuild your program around the 2025 proposal. Instead, know which of your patients and workflows depend on the temporary flexibilities, and have a plan for each outcome.

Buprenorphine has its own permanent rule

A separate final rule, Expansion of Buprenorphine Treatment via Telemedicine Encounter (21 CFR 1306.51), was published in January 2025 and, after two delays, took effect December 31, 2025. It allows practitioners registered to dispense buprenorphine to prescribe it for opioid use disorder through a telemedicine encounter, including audio-only, without a prior in-person visit. Its key conditions:

• Six-month limit. Prescribing under this rule without an in-person evaluation is limited to a six-month supply in total, which can be split across multiple prescriptions. After that, further prescribing requires an in-person evaluation or another permitted form of telemedicine.
• PDMP check first. Before prescribing, the practitioner must review the prescription drug monitoring program (PDMP) data for the state where the patient is located, covering the past year, and record the date and time of the review.
• If the PDMP can't be checked, the practitioner must document why and each attempt, and may prescribe only a 7-day supply at a time, repeating the attempt each time.
• Pharmacist identity check. The pharmacist must verify the patient's identity before filling.

While the temporary flexibilities remain in effect, practitioners may follow those instead, which DEA notes impose fewer requirements. After they end, buprenorphine prescriptions issued without an in-person evaluation must meet this rule, unless the final special registration rule creates another pathway.

What this means for opioid treatment programs

The federal OTP rule (42 CFR Part 8, revised in 2024) has its own telehealth provisions for admission, separate from DEA's prescribing flexibilities. Under 42 CFR 8.12(f)(2)(v):

• The screening and full examination for a new patient may be done by telehealth if the practitioner determines an adequate evaluation can be done that way.
• For methadone (Schedule II), audio-visual telehealth must be used, unless it isn't available to the patient. Audio-only is acceptable then, but only when the patient is with a licensed practitioner registered to prescribe or dispense controlled medications.
• For buprenorphine (Schedule III), audio-visual or audio-only may be used.

Telehealth doesn't replace the in-person exam entirely. The rule still requires a full in-person physical examination, including required lab work, within 14 calendar days of admission (42 CFR 8.12(f)(2)(iii)).

Medicare also pays for some OTP services by telehealth, including audio-only periodic assessments when video isn't available, where SAMHSA and DEA rules allow. If your program relies on telehealth for intake or follow-up, confirm with your State Opioid Treatment Authority how your state applies these provisions, and whether any state rule is stricter.

Medicare telehealth: extended through 2027

Medicare's telehealth flexibilities are a separate issue from DEA's prescribing rules. The Consolidated Appropriations Act, 2026 (Public Law 119-75, signed February 3, 2026) extended them through December 31, 2027. According to CMS:

• Through 2027, beneficiaries can receive Medicare telehealth services wherever they are, and audio-only services at home remain available.
• Behavioral health telehealth in the patient's home is permanent under earlier law. What is delayed is the in-person requirement for mental health telehealth (an in-person visit within six months before the first telehealth service), which takes effect after December 31, 2027. Patients who began mental health telehealth at home on or before that date will be treated as established patients and will need an in-person visit at least every 12 months.

Medicaid and commercial payers set their own telehealth rules, so check each payer separately.

What to update in your policies now

Telehealth prescribing policy

• State which prescribing pathway applies to each type of prescription: the temporary flexibilities, the buprenorphine rule, or an in-person evaluation.
• Include a contingency section for January 1, 2027 covering each of the three outcomes above.
• Record the modality used (audio-video or audio-only) and the patient's location at the time of each telemedicine visit. This is a recommended practice rather than a federal documentation requirement, but it makes every other check possible.

Buprenorphine procedures

• Add the PDMP review step for the patient's state, with the date and time documented.
• Add the documentation and 7-day limit for when the PDMP can't be reached.
• Track each patient's telemedicine prescribing from the first prescription, and schedule in-person evaluations before the six-month limit is reached.

Clinical operations

• Identify patients who started controlled-substance treatment by telemedicine without an in-person visit, and plan for their continuity of care.
• Confirm that each prescriber is licensed in the state where each patient is located. DEA generally requires registration in that state as well; confirm DEA's current position for your situation.
• Review state telehealth and controlled-substance rules, which can be stricter than federal rules.

Forms and training

• Update telehealth consent forms and documentation templates for the items above.
• Train prescribers, nurses and intake staff on what changes, and when, if the flexibilities lapse.

We'll update this article when the final rule or another extension is published.

Sources

1. DEA and HHS, "Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications," 90 FR 61301, December 31, 2025. govinfo.gov
2. OIRA review record, RIN 1117-AB40, Special Registrations for Telemedicine (final rule received August 25, 2026). reginfo.gov
3. Unified Agenda entry, RIN 1117-AB40. reginfo.gov
4. DEA, "Special Registrations for Telemedicine and Limited State Telemedicine Registrations" (proposed rule), January 17, 2025. federalregister.gov
5. DEA and HHS, "Expansion of Buprenorphine Treatment via Telemedicine Encounter," 90 FR 6504, January 17, 2025. govinfo.gov
6. DEA, delay of effective date to December 31, 2025, 90 FR 13410, March 24, 2025. govinfo.gov
7. 42 CFR 8.12, Federal opioid use disorder treatment standards (2025 edition), including 8.12(f)(2)(iii) and (v). govinfo.gov
8. Consolidated Appropriations Act, 2026, Public Law 119-75. govinfo.gov
9. CMS, Telehealth FAQ, updated February 4, 2026. cms.gov
10. CMS, Calendar Year 2025 Medicare Physician Fee Schedule final rule fact sheet (OTP telehealth). cms.gov

Checked against the primary sources listed above as of October 29, 2026. Rules and dates can change; confirm current requirements before acting. This article is general information, not legal advice.