Prescribing across state lines: licensure, telehealth and controlled substances in 2026

Telehealth lets you see a patient anywhere, but licensure is still granted state by state, and prescribing controlled substances by telemedicine depends on a federal exception that expires at the end of 2026. Here is where things stand as of September 2026, and what to check before you prescribe to a patient in another state.

Licensure follows the patient, not the clinician

For licensing purposes, a telehealth visit takes place where the patient is physically located during the visit, not where you sit or where the patient usually lives. HHS guidance says clinicians must be licensed or legally permitted to practice in the state where the patient is located.

Confirm location at every visit. HHS recommends verifying the patient's location, and getting consent, before each appointment. A regular patient logging on from a vacation rental two states away may be outside your license.
The standard of care does not drop. The Federation of State Medical Boards' 2022 model policy applies the same standard of care and professional ethics to telemedicine as to in-person care.
Exceptions are narrow. The FSMB model lists exceptions such as physician-to-physician consultations and episodic follow-up for established patients. HHS notes that some states have temporary practice laws for traveling patients or allow telehealth from a bordering state. Don't assume any of them covers ongoing direct-to-patient prescribing. Check the patient's state.

Ways to practice in more states

A full license in each state is still the default. The alternatives:

Telehealth registrations

Some states let out-of-state clinicians register for telehealth instead of getting a full license. Typical conditions, according to HHS: an unrestricted license elsewhere, no past discipline, malpractice coverage, no office or in-person care in the state, and annual renewal. Florida, for example, requires out-of-state telehealth providers to register and bars them from opening an office or seeing patients in person there.

The Interstate Medical Licensure Compact (physicians)

The IMLC is an expedited pathway, not a national license. You qualify through a "state of principal license," then receive a separate license from each member state you choose, each with its own rules and renewals. You need a full, unrestricted license in a member state and no history of license discipline, criminal history or controlled-substance actions. The Commission's official site, imlcc.com, lists 44 member states plus the District of Columbia and Guam. Some newer members were still implementing as of September 2026.

The PA Licensure Compact

The PA Compact had 29 member states as of August 28, 2026, but it is not yet issuing privileges to practice. The Commission projects that privileges will be available in early 2027. Until then, PAs need a license in each state.

The APRN Compact (nurse practitioners)

The APRN Compact would give nurse practitioners and other APRNs a multistate license, but it takes effect only after seven states enact it. It had not reached that number as of September 2026. NPs still need a license in each state and must follow each state's scope-of-practice rules.

Synchronous versus asynchronous care: states disagree

States differ on whether a patient relationship can start without a live visit:

Texas recognizes a relationship formed through synchronous audio-video. It also accepts asynchronous store-and-forward technology if the practitioner uses clinically relevant photos or video, or the patient's relevant records, such as history, labs and prescription history. The standard of care and follow-up requirements still apply.
Arkansas says a relationship cannot be established only through an internet questionnaire, email, patient-generated history, text messaging or fax. A real-time audio-video exam that provides information at least equal to an in-person exam can establish one.

If your intake starts with an online questionnaire, have each patient state's rules reviewed before you rely on it.

Controlled substances: the Ryan Haight Act and the 2026 flexibilities

The Ryan Haight Act of 2008 generally requires at least one in-person medical evaluation before a practitioner prescribes a controlled substance remotely, with narrow statutory exceptions. According to DEA, once you have done an in-person evaluation, those remote-prescribing requirements no longer apply to that practitioner-patient relationship. DEA's other rules still do.

That matters for hormone clinics. Federal law classifies testosterone as an anabolic steroid, and anabolic steroids are Schedule III. States schedule it too. Florida, for example, lists testosterone in its own Schedule III.

What is allowed through December 31, 2026

A fourth temporary extension of the COVID-era telemedicine flexibilities, published December 31, 2025, runs through December 31, 2026. Until then, a DEA-registered practitioner may prescribe Schedule II–V controlled substances by telemedicine without a prior in-person evaluation if all of these conditions are met:

The prescription is for a legitimate medical purpose, in the usual course of professional practice.
It follows a communication using an "interactive telecommunications system" as defined in 42 CFR 410.78(a)(3). That means real-time, two-way audio and video, with audio-only allowed only in limited circumstances.
Your DEA registration authorizes that class of controlled substance, or you are exempt from registration.
The prescription meets all other requirements of 21 CFR part 1306.

An asynchronous questionnaire or chat exchange does not meet the interactive-communication condition.

What comes next: special registration

DEA's January 2025 proposal would create special registrations for telemedicine prescribing and for online platforms. Schedule III–V drugs would need a standard registration and Schedule II drugs an advanced one. It would also require a DEA-issued State Telemedicine Registration for each state where patients are treated, nationwide prescription drug monitoring program (PDMP) checks, patient identity verification, and new recordkeeping and reporting. DEA received more than 6,475 comments.

DEA sent a final rule to the White House Office of Information and Regulatory Affairs on August 25, 2026. It was still under review in September, and the federal regulatory agenda lists final action for November 2026. The text under review is not public, so the final rule may differ from the proposal. Separate final rules for buprenorphine treatment and for VA patients took effect December 31, 2025. Neither is a general pathway.

One question to take to counsel: DEA registrations are state-based, and the proposal would require registration in each patient's state. Confirm your registrations before prescribing controlled substances across state lines.

A checklist for the rest of 2026

Confirm your license, registration or compact status in every state where patients are located when you see them.
Flag controlled-substance patients who started treatment by telemedicine without an in-person evaluation, and plan for January 1, 2027.
Use real-time audio-video for controlled-substance visits, and record the modality in the chart.
Apply state rules on top of federal ones. Florida, for example, bars telehealth prescribing of Schedule II drugs except in listed settings, such as psychiatric treatment, hospital inpatient care, hospice and nursing homes.
Watch the Federal Register for DEA's final rule.
Remember the pharmacy. States license pharmacies too. Texas, for example, issues nonresident (Class E) licenses to out-of-state pharmacies that deliver to patients in Texas. If you order through MedGrid, which verifies clinicians' NPI, DEA and state licenses, patient-specific prescriptions route to a partner pharmacy licensed in the patient's state. It is not a telehealth provider, so licensure and prescribing decisions stay with you.

This article is general information, not legal advice. Rules vary by state; confirm specifics with your counsel and your state boards.