DEA Telehealth Prescribing Rules 2026: Planning for the December Cliff

Background: Four Years of Temporary Flexibilities

When the COVID-19 public health emergency was declared in March 2020, the DEA exercised its authority to temporarily waive the requirement under the Ryan Haight Online Pharmacy Consumer Protection Act that a prescriber conduct an in-person medical evaluation before prescribing controlled substances via telehealth. This was a pragmatic response to a sudden public health reality: patients could not safely visit prescribers in person, but they still needed medications — including controlled substances critical for managing substance use disorders, ADHD, anxiety, and other conditions.

What was intended as a temporary emergency measure has been extended four times:

The pattern is clear: the DEA has been unable or unwilling to finalize a permanent framework, and Congress has not legislated one. Each extension creates another year of regulatory uncertainty that prevents practices from making long-term operational decisions about their telehealth prescribing models. The repeated extensions also create a "cry wolf" dynamic where practices assume another extension will come and fail to prepare for the scenario in which it does not.

Affected Medications and Schedules

The telehealth prescribing flexibilities apply to all DEA-scheduled controlled substances (Schedules II through V). For behavioral health, the medications with the most significant clinical and operational impact are:

Schedule III: Buprenorphine (Suboxone, Subutex, Sublocade)

Buprenorphine is the most widely prescribed medication for opioid use disorder (OUD) and is classified as a Schedule III controlled substance. The ability to initiate buprenorphine prescribing via telehealth has been one of the most consequential effects of the COVID flexibilities. SAMHSA data shows that telehealth buprenorphine prescribing increased by over 300% between 2019 and 2023, with the largest gains in rural areas where access to in-person OUD treatment providers is limited.

If the flexibilities expire, new patients cannot be started on buprenorphine via telehealth. Existing patients who were initiated exclusively via telehealth would be in a regulatory gray area regarding prescription renewals. This is the single highest-impact clinical scenario for the behavioral health field.

Schedule II: Stimulants (Adderall, Vyvanse, Ritalin, Concerta)

Stimulant prescribing for ADHD via telehealth expanded dramatically during the pandemic. Companies like Done Health and Cerebral built entire business models around telehealth ADHD assessment and stimulant prescribing. While these companies have faced regulatory scrutiny, the underlying clinical need is real: ADHD is significantly underdiagnosed in adults, and telehealth expanded access to evaluation and treatment. Schedule II substances face the strictest prescribing requirements, and the expiration of flexibilities would require an in-person evaluation before any new stimulant prescription.

Schedule IV: Benzodiazepines (Alprazolam, Clonazepam, Lorazepam, Diazepam)

Benzodiazepine prescribing for anxiety disorders via telehealth is common in psychiatric practice. While prescribing guidelines increasingly recommend against long-term benzodiazepine use, many patients are maintained on stable benzodiazepine regimens managed via telehealth. The expiration of flexibilities would require these patients to complete an in-person visit before their next prescription renewal if their prescribing relationship was established exclusively via telehealth.

Other Affected Medications

• Gabapentin (Schedule V in some states): Increasingly scheduled due to misuse potential; used extensively in pain management and sometimes in BH for anxiety and mood stabilization.
• Zolpidem (Ambien, Schedule IV): Prescribed for insomnia, commonly managed via telehealth psychiatry.
• Testosterone (Schedule III): Relevant for gender-affirming care programs that use telehealth for medication management.
• Tramadol (Schedule IV): Sometimes prescribed by BH providers managing co-occurring pain conditions.

Impact on MAT/OUD Programs

The intersection of the DEA telehealth cliff with the opioid crisis makes this one of the most consequential regulatory issues in behavioral health. The numbers tell the story:

• Over 107,000 Americans died of drug overdoses in 2023, with synthetic opioids driving the majority of deaths.
• Buprenorphine is the most effective medication for OUD, with evidence showing 50% or greater reduction in illicit opioid use and overdose mortality.
• SAMHSA estimates that only 22% of people with OUD receive any form of treatment, with medication access being the primary barrier.
• Telehealth buprenorphine initiation expanded the prescriber pool from a small number of waivered in-person providers to any DEA-registered practitioner with prescribing authority.
• Research published in JAMA Network Open found that patients initiated on buprenorphine via telehealth had comparable retention rates and treatment outcomes to in-person initiations.

If the flexibilities expire without a permanent framework, the impact on MAT/OUD programs is severe:

Programs That Will Be Most Affected

• Telehealth-first OUD programs: Organizations that built their treatment model around telehealth buprenorphine access face an existential operational challenge. Patients in rural areas may be 50 to 100 miles from the nearest in-person prescriber.
• Hub-and-spoke MAT networks: Many states use a hub-and-spoke model where a central hub manages inductions and spokes provide ongoing maintenance. Telehealth spokes would need to convert to in-person, which may not be feasible for all locations.
• Jail and prison re-entry programs: Telehealth buprenorphine prescribing has been critical for initiating MAT during incarceration and maintaining it during re-entry. In-person requirements would disrupt this continuity of care.
• Emergency department bridge programs: ED-initiated buprenorphine with telehealth follow-up has become a standard-of-care model. If follow-up prescribers cannot continue the prescription via telehealth without having seen the patient in person, this care pathway breaks down.

For a deeper look at how addiction treatment EHR systems can support MAT workflows and buprenorphine prescribing compliance, see our guide to the best EHR for addiction treatment.

What Your Billing Team Needs to Do

Regardless of whether a fifth extension or permanent rule materializes, every behavioral health practice that prescribes controlled substances via telehealth should execute the following action plan. The cost of preparing and not needing to is minimal. The cost of not preparing and facing a hard January 1, 2027 cutoff is severe.

Phase 1: Audit and Assessment (Now Through April 2026)

1. Audit your telehealth prescribing volume. Run a report of every patient currently receiving a controlled substance prescription from your practice where the prescribing relationship was established entirely via telehealth (no in-person encounter with the prescribing clinician). This is your "at-risk" patient population. Segment by schedule: Schedule II (stimulants), Schedule III (buprenorphine), and Schedule IV (benzodiazepines, sleep medications). The total count and the per-prescriber breakdown will drive the rest of your planning.
2. Calculate revenue exposure. For each at-risk patient, calculate the annualized revenue including prescribing visits, medication management follow-ups, and ancillary services. Sum this across all at-risk patients to determine the total revenue at risk if these patients cannot continue receiving controlled substance prescriptions via telehealth. This number is your business case for investing in preparation.
3. Identify patients needing in-person conversion. For every at-risk patient, determine whether an in-person visit with the prescribing clinician is logistically feasible. Consider distance, transportation, mobility limitations, and scheduling availability. Patients who cannot realistically complete an in-person visit need a different care pathway (referral to a local prescriber, transition to non-controlled alternatives, etc.).

Phase 2: In-Person Conversion (May Through November 2026)

4. Build scheduling capacity for the in-person surge. If you have 200 telehealth-only controlled substance patients who need in-person evaluations, you need 200 in-person appointment slots spread over 7 months. That is approximately 30 additional in-person appointments per month, or about 7 per week. Calculate this for your practice and determine whether you need to add clinic hours, open additional days, or secure additional clinical space. Start scheduling these appointments now to avoid a crush in Q4.
5. Prioritize by clinical urgency. Schedule buprenorphine patients first. Interrupting MAT creates an immediate overdose risk. Schedule stimulant patients second. Schedule benzodiazepine patients third unless they are on high-dose or long-term regimens where abrupt discontinuation carries withdrawal risk. This triage ensures that the highest-risk patients are converted first if your scheduling capacity is limited.
6. Document the in-person encounter specifically. The in-person evaluation must be documented as a medical evaluation in the patient's record by the prescribing clinician. Ensure your documentation template captures the elements required under the Ryan Haight Act: a face-to-face, in-person medical evaluation by the prescribing practitioner. A telehealth visit, phone call, or visit with a different provider does not satisfy this requirement.
7. Set up referral pathways for patients who cannot come in person. For patients who live too far from your practice for an in-person visit, identify local prescribers who can assume controlled substance management. Begin warm handoffs early. Transferring prescribing responsibility takes time, particularly for buprenorphine patients where treatment continuity is essential.

Phase 3: Operational Readiness (October Through December 2026)

8. Implement hybrid workflow protocols. Establish workflow protocols that distinguish between patients with and without an in-person encounter on file. After December 31, prescribers need real-time visibility into each patient's in-person evaluation status before prescribing controlled substances via telehealth.
9. Update scheduling and billing templates. If the flexibilities expire, some telehealth medication management visits will need to convert to in-person or hybrid models. Update your scheduling templates, telehealth workflows, and billing code configurations to accommodate the change. Modifier 95 (synchronous telehealth) would no longer be applicable for controlled substance prescribing visits with patients lacking an in-person encounter.
10. Prepare patient communications. Draft patient notification letters and portal messages explaining the potential change and what they need to do. Have these ready to send by November if no extension or permanent rule has been announced.

Revenue and Financial Impact

The financial impact of the telehealth prescribing cliff depends on your practice's controlled substance prescribing volume and telehealth mix. Here is a framework for quantifying exposure:

Direct Revenue at Risk

Patients who cannot or will not complete an in-person visit may discontinue treatment, seek care elsewhere, or simply stop refilling prescriptions. For each lost patient, the revenue impact includes:

• Medication management visits: Typically $100-$200 per visit (reimbursement after payer adjustments), with visits occurring monthly to quarterly. Annual revenue per patient: $400-$2,400.
• Associated services: Drug screening, therapy sessions, group therapy, and care coordination often bundled with medication management. Loss of the prescribing relationship frequently leads to loss of these ancillary service revenues as well.
• Program-level impact: MAT programs where buprenorphine prescribing is the anchor service face revenue disruption across the entire program if prescribing capacity is constrained.

Operational Cost of Conversion

Even if you successfully convert all at-risk patients to in-person relationships, there are transition costs:

• Clinic space costs: Practices that are primarily telehealth may need to lease or expand physical space for in-person visits. Short-term lease or sublet arrangements in medical office space run $25-$50 per square foot annually.
• Scheduling and administrative overhead: In-person visits require check-in staff, room turnover, cleaning protocols, and longer time blocks than telehealth visits. Expect a 20-30% reduction in patients seen per day when converting telehealth slots to in-person.
• Patient attrition during conversion: Historical data from telehealth programs suggests 10-15% patient attrition when requiring an in-person visit that was not previously needed. For patients with transportation barriers, attrition rates are higher.

EHR and Technology Implications

The operational preparation for the December cliff requires specific technology capabilities that should be configured now:

In-Person Encounter Tracking

Your EHR must be able to track and display whether a specific prescriber-patient relationship includes a documented in-person evaluation. This is not a standard EHR field in most systems. You may need to create a custom flag, form field, or tracking mechanism that allows prescribers to see at a glance whether they can legally prescribe controlled substances to a given patient via telehealth. AZZLY Rize and other behavioral health-focused EHR platforms offer configurable tracking fields and clinical alerts that can be adapted for this purpose, enabling prescribers to immediately see a patient's in-person encounter status when opening their chart.

Prescription Monitoring and PDMP Integration

Regardless of the DEA telehealth rules, Prescription Drug Monitoring Program (PDMP) queries remain required for controlled substance prescribing in most states. Ensure your EHR or e-prescribing system maintains seamless PDMP integration. If you are converting telehealth patients to in-person workflows, verify that your in-person workflow templates include PDMP query steps.

Telehealth Platform Configuration

If the flexibilities expire, your telehealth platform needs to accommodate a hybrid model where controlled substance visits may need to be in-person while non-controlled medication management and therapy continue via telehealth. The visit type configuration in your scheduling and telehealth systems should distinguish between:

• Telehealth visits for non-controlled medications (unaffected)
• Telehealth visits for controlled substances with established in-person relationship (permitted)
• Visits requiring in-person component for controlled substance prescribing (must be in-person or hybrid)

E-Prescribing for Controlled Substances (EPCS)

EPCS workflows should be reviewed to ensure they integrate with whatever in-person encounter tracking mechanism you implement. The prescriber's ability to send an electronic controlled substance prescription via telehealth should be linked to verification that the Ryan Haight Act in-person requirement has been met (if the flexibilities expire). EHR platforms with strong compliance controls can build this verification into the prescribing workflow itself, preventing a prescription from being sent if the in-person encounter requirement has not been documented.

Reporting and Compliance Dashboards

Build or configure reports that show: total controlled substance prescribing volume by modality (telehealth vs. in-person), patients with controlled substance prescriptions who lack an in-person encounter with the prescribing clinician, and conversion progress over time. This dashboard is the management tool for tracking your preparation progress. Platforms like Ease provide the reporting flexibility to build custom compliance dashboards that track these specific metrics across your provider panel.

For a comprehensive comparison of EHR platforms and their controlled substance prescribing, telehealth integration, and compliance capabilities, see our behavioral health EHR comparison.

Frequently Asked Questions

What happens to telehealth prescribing of controlled substances on December 31, 2026?

The current DEA temporary rule allowing prescribing of Schedule II-V controlled substances via telehealth without a prior in-person examination expires on December 31, 2026. If no permanent rule or further extension is enacted, the Ryan Haight Online Pharmacy Consumer Protection Act requirements fully reinstate. Prescribers would need to have conducted at least one in-person medical evaluation of the patient before prescribing or renewing any controlled substance via telehealth. This applies to all controlled substances including buprenorphine, stimulants, benzodiazepines, and all other Schedule II through V medications.

Can I still prescribe buprenorphine via telehealth after the flexibilities expire?

If the flexibilities expire without a permanent rule or extension, you can continue prescribing buprenorphine via telehealth ONLY for patients with whom you have previously conducted an in-person medical evaluation. New patients would need to be seen in person before buprenorphine can be prescribed via telehealth. For existing patients initiated exclusively via telehealth, the safest approach is to schedule in-person evaluations before December 31, 2026 to establish the required in-person relationship.

Will DEA issue a permanent telehealth prescribing rule?

As of February 2026, no permanent rule has been finalized. DEA published proposed rules in both 2023 and 2024 that would have created a permanent framework, but neither has been finalized. The proposed rules included provisions for initial telehealth prescribing of Schedule III-V substances with a 30-day supply limit before requiring an in-person visit, and stricter requirements for Schedule II substances. There is bipartisan Congressional interest in codifying telehealth prescribing flexibility, but no legislation has been enacted.

What is the Ryan Haight Act and how does it affect telehealth prescribing?

The Ryan Haight Online Pharmacy Consumer Protection Act (2008) requires that a prescriber conduct at least one in-person medical evaluation of a patient before prescribing a controlled substance via the internet or telehealth. During the COVID-19 public health emergency, DEA temporarily waived the in-person requirement, and has extended that waiver four times. If the waiver expires, the full Ryan Haight Act requirements reinstate.

How should I prepare my practice for the potential December 2026 cliff?

Start now with four steps: First, audit your current telehealth prescribing volume and identify every patient receiving controlled substances where the relationship was established exclusively via telehealth. Second, begin scheduling in-person evaluations between now and November 2026. Third, build scheduling capacity for the in-person evaluation surge in Q3-Q4 2026. Fourth, implement hybrid workflow protocols in your EHR that track the in-person encounter status for each patient-prescriber relationship involving controlled substances.

Does this affect prescribing of non-controlled medications via telehealth?

No. The Ryan Haight Act and the DEA telehealth flexibilities apply only to controlled substances (Schedules II through V). Prescribing non-controlled medications via telehealth — including SSRIs, SNRIs, antipsychotics, mood stabilizers, and other non-scheduled psychiatric medications — is not affected by the December 2026 expiration. State-level telehealth prescribing rules may impose additional requirements, but the federal DEA framework only governs controlled substance prescribing.