The 'Telemedicine Cliff' is Back: Will DEA Finalize Its Rule Before December 31?
By Hunter DeKoninck
Published: November 11, 2026
The telemedicine flexibilities that have allowed DEA-registered practitioners to prescribe controlled substances without in-person evaluations are set to expire on December 31, 2026. DEA's final telemedicine rule, which is meant to replace those flexibilities, has been under White House review since August 25th and theere has been no mention of its progress. Moreover, the text of that final rule has not been made public, so we do not actually know what DEA's telemedicine "solution" looks like. With about seven weeks left, the question is whether DEA can finish the rule in time and, if not, what it will do.
Where Do Things Stand?
Under the Ryan Haight Act, a practitioner generally must conduct an in-person evaluation before prescribing a controlled substance remotely. DEA has suspended that requirement through a series of temporary extensions, most recently the Fourth Temporary Extension, which explains that the extension was needed to give DEA time to finalize its proposed rule and give providers time to come into compliance with it. DEA's January 2025 proposed rule, 90 FR 6541, would create three special registrations (telemedicine prescribing, advanced telemedicine prescribing, and telemedicine platform), plus state telemedicine registrations, with electronic prescribing, identity verification, and prescription drug monitoring program checks.
The history matters for what comes next. DEA has now extended the telemedicine flexibilities four times and the lead time of those extensions being granted ahead of their expiration has shrunk each round. If you recall, we found ourselves in the same position last year, which ended with DEA securing the extension on the same day it was set to expire. (See my posts leading up to the last extensions: Alert: DEA’s Telemedicine Allowances ALMOST Extended (Again) and Breaking News: DEA’s Telemedicine Flexibilities Extended).
In August, when DEA’s agenda moved the special registration rule to the final rule stage with a November 2026 target, I cautioned against assuming November would hold or that the substance would survive (DEA’s Telemedicine Special Registration Rule Just Moved to Final Rule Stage). Eight days after that post, DEA’s final rule reached OIRA and it has sat there ever since.
Can DEA Finalize a Rule in Time?
Publishing the final rule by year-end is plausible. Having it fully operational by January 1st is not. OIRA's 90-day review window, which can be extended once by 30 days, runs to roughly November 23rd, or December 23rd if extended, though those limits govern OIRA's review and not DEA's publication. DEA’s agenda targeted “November 2026” for final action, as I noted back in August, and OIRA has held a steady run of stakeholder meetings, with another scheduled November 12th.
The harder problem is implementation. A final rule would ordinarily take effect at least 30 days after publication (or 60 days if OMB treats it as a major rule). More importantly, the rule needs infrastructure that does not yet exist: application forms, fees, processing capacity, and state-by-state registrations.
Once implemented, it will take even longer for the industry to come into compliance. DEA's own rationale for the last extension was to give providers time to comply with any new registration, recordkeeping, or security requirements. A hard January 1st move to the new rule would contradict stated consideration. This piece alone, makes another extension more likely (or, at a minimum, a significant grace period for the industry to adjust to the new rule before DEA enforces it).
Capacity limitations within DEA likely present even more of a challenge. DEA is simultaneously building a new registration category for medical marijuana dispensaries on a compressed timeline, which, as I wrote in September, has produced issues across its divisions (Marijuana’s Rescheduling Hits Reality),. Standing up three more registration types, plus state registrations, on top of that is a large ask. This is my observation, not something DEA has said.
If it Can’t Finalize in Time, What Will DEA Do?
In my view the most likely outcome is a fifth temporary extension, issued jointly with HHS, probably in mid-to-late December given how late DEA has acted before. The second possibility is a final rule published with a delayed effective date or compliance period, paired with transitional relief for the flexibilities.
The least likely outcome is a clean lapse. DEA has called that scenario the “telemedicine cliff” and has avoided it every time.
How Should the Industry Prepare?
Telehealth companies and prescribers should plan for three scenarios rather than one: an extension, a final rule with a transition, and a lapse. In any case, patients who have already had at least one in-person evaluation are not affected by the Ryan Haight requirement, so the real exposure is patients never seen in person.
Pharmacies will face verification and corresponding responsibility problems. If special registrations arrive, prescriptions would carry new registration numbers, and pharmacies will need to confirm them. In a lapse scenario, pharmacies could receive prescriptions that are no longer valid and pharmacists will need to reject them to fulfill their corresponding responsibility.
Distributors should expect shifts in demand among telehealth-dependent pharmacy customers, so they will need to keep customer due diligence current.
Finally, its worth noting again that the text of the final rule is not public so, despite all that it could be doing to prepare itself, the industry doesn’t even know what it needs to prepare for or adjust to.
My Read
I would not bet on a final rule that is operational by January 1st and I would not assume DEA announces its plan early. I think it is most likely that we get a last-minute extension, with compliance planning for an actual rule to come in 2027. Watch the Federal Register public inspection list and OIRA's review page through December.
This post is for general informational purposes and does not constitute legal advice. Consult counsel regarding your specific compliance obligations.
