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December 31, 2026 is already on your calendar, whether you have written it down or not.
That is the date the DEA and HHS set when they issued the fourth temporary extension of the telemedicine prescribing flexibilities for controlled substances.1 It gives clinics a full year of runway (the earlier extension is covered in DEA Extends Telemedicine Flexibilities Through 2025). It does not give them certainty, because the permanent rule is still unwritten.
This piece covers what the extension allows, what it does not do and how I would plan around it. I am a marketer and operator, not an attorney, and this is educational content, not legal advice.
What does the 2026 extension actually allow?
It keeps the pandemic-era rule alive for another year. Practitioners with the right DEA registration may prescribe Schedule II to V controlled substances after a telemedicine encounter, with no first in-person visit required.1
The four conditions
The rule is not a blank check. Per the Federal Register text, the prescription must meet all of these:1
- A legitimate medical purpose, issued by a practitioner acting in the usual course of professional practice.
- A real encounter, conducted through an interactive telecommunications system as defined in the rule.
- The right registration, meaning the practitioner is authorized under their DEA registration for the class of drug prescribed, or is exempt from registration.
- Everything else in Part 1306 still applies, which is the DEA's baseline prescription requirements.
Two other rules took effect the same day
Two final rules published in January 2025 also took effect on December 31, 2025: one covering buprenorphine treatment via telemedicine and one on continuity of care for VA patients. The rule says a practitioner may rely on the temporary extension even if they could also qualify under one of those, and only has to meet a final rule's requirements when the prescription is issued under that rule.1
What does the extension not do?
This is where clinics get into trouble, so I would slow down here.
| What the extension does | What it does not do |
|---|---|
| Removes the in-person evaluation requirement for qualifying prescriptions | Make the arrangement permanent |
| Applies through December 31, 2026 | Replace the need to check each state's rules |
| Is a deregulatory action with no new regulatory requirements | Cover prescriptions that fail its four conditions |
| Gives the DEA time to finalize permanent rules | Guarantee another extension after 2026 |
State law is the piece people forget. Frier Levitt notes that federal rules intersect with state law, which must be checked in each jurisdiction where remote practice occurs, and suggests getting healthcare counsel involved on records, data security and informed consent.3 If you treat patients across state lines, that work does not go away; licensing across state lines is the constraint to plan around.
What could change after 2026?
Three things are in play.
A permanent special registration
In January 2025 the DEA proposed a framework called Special Registration for Telemedicine (I covered it in what a permanent rule could require). The extension notice says the agency received more than 6,475 comments and is still considering them, along with listening sessions and consultations.1 McDermott's read is that the current administration has not moved to finalize the proposed approach, and that it remains unclear whether it will.2
Another extension
The DEA has extended these flexibilities four times now, and the stated reason this time was to avoid a "telemedicine cliff" and to give regulators time to finalize permanent rules.1 History suggests another extension is possible. History is not a plan.
A gap
Nobody can rule out a lapse. McDermott points to the Medicare telemedicine flexibilities, which ended abruptly on September 30, 2025, as an example of how fast a cliff can arrive.2
Hope is not a contingency plan. A date on a federal notice is.
How should a clinic plan the year?
Start with a question that costs nothing: does any part of your formulary involve a scheduled drug? If none of your prescribing touches Schedule II to V, this rule does not govern your core service, and your counsel can confirm that in a short call. If any of it does, you are carrying a December 31 dependency, and I would treat it like one.
- Map the dependency. List every service, product and revenue line that relies on prescribing a controlled substance without an in-person visit. Put a dollar figure next to each.
- Write three scenarios. One where the flexibilities are extended again, one where a permanent rule lands with new registration steps, one where there is a gap. Next to each, write what you would change and how many weeks that would take.
- Set a decision date. Pick a month in the second half of the year when you review where the rulemaking stands and trigger the right scenario. Do not wait for December.
- Keep your records audit-ready. Document the legitimate medical purpose, the encounter and the registration for every prescription, in a form your counsel approves.
- Check every state you serve. Track licensure and each state's telemedicine rules in one place.
Do not market around the loophole
This is the part that touches my side of the business. Your ads, landing pages and intake flow should never promise that a patient will never need an in-person visit for a scheduled medication, because the rule that allows it has an end date and conditions. Describe the process as it is: an evaluation by a licensed clinician, who decides whether a prescription is appropriate.
What should the next twelve months look like?
2025 in review shows how fast the ground moved last year. Quarter one, map the dependency and book time with counsel. Quarter two, write the scenarios and check state rules. Quarter three, hold the decision review as the rulemaking picture clears. Quarter four, act on the scenario that is playing out.
- Quarter oneMap the dependency, book time with counsel
- Quarter twoWrite the three scenarios, check state rules
- Quarter threeDecision review as the rulemaking picture clears
- Quarter fourAct on the scenario that is playing out
I would also keep one eye on the Federal Register. The extension itself says the DEA is still reviewing comments on the permanent approach,1 so a proposed or final rule is the signal that moves you from planning to doing.
A year of runway is a gift. Use it to build options, not to relax. How I think about the funnel side of that is on my telehealth page.
Educational content, not legal advice. Consult your attorney and compliance team about your specific prescribing and registration obligations.
Keep building.Ekai
Questions people ask
How long do the DEA telemedicine flexibilities last?
The fourth temporary extension runs from January 1 through December 31, 2026. Unless the DEA and HHS extend it again or replace it with permanent rules, the flexibilities end on that date.
What do the flexibilities allow?
DEA-registered practitioners may prescribe Schedule II to V controlled substances through telemedicine without a prior in-person medical evaluation, as long as the rule's conditions are met, including a legitimate medical purpose and an interactive telecommunications encounter.
What is the special registration for telemedicine?
It is a permanent framework the DEA proposed in January 2025. The agency received more than 6,475 comments and said in the extension that it is still considering them. It has not been finalized.
Do the federal flexibilities override state law?
No. Federal telemedicine rules sit alongside state law, so you still need to check the rules in every state where a patient is located. This is educational content, not legal advice.
Sources
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