Build the program for a lapse. If the DEA telemedicine flexibilities end on December 31, 2026 with nothing in their place, a testosterone patient you have never examined in person needs one in-person evaluation, or a visit with a DEA-registered practitioner in the room. A program that already works that way runs unchanged under an extension or a final rule.
Where the federal rule stands on September 24, 2026
Testosterone is Schedule III (21 C.F.R. § 1308.13). The rule that lets you start it by video without an in-person exam, 21 C.F.R. § 1307.41, says its authorization “expires at the end of December 31, 2026.”
As of September 24, 2026, the Federal Register shows no fifth extension and no final special registration rule. The final rule under RIN 1117-AB40 has been under White House review since August 25, 2026, according to the review office’s own list dated September 24. The regulatory agenda targets final action in November 2026. That is a target, and the text is not public. The three-scenario breakdown covers the news. This post covers the build.
| Outcome on January 1, 2027 | What a program built for the lapse does |
|---|---|
| Fifth extension | Keeps running. The in-person path becomes optional again. |
| Final special registration rule | Keeps running for examined patients while you evaluate the new registration. The January 2025 proposal required PDMP checks, identity verification and location records, which you already keep. |
| Lapse with no replacement | Keeps running. New patients go through the in-person path before the first prescription. |
The in-person path the statute already allows
The Ryan Haight Act defines a valid prescription as one issued for a legitimate medical purpose by “a practitioner who has conducted at least 1 in-person medical evaluation of the patient,” or by a covering practitioner (21 U.S.C. § 829(e)(2)(A)). An in-person evaluation is one “conducted with the patient in the physical presence of the practitioner, without regard to whether portions of the evaluation are conducted by other health professionals” (§ 829(e)(2)(B)(i)).
Three routes follow from the text.
- The prescriber sees the patient once in person. DEA stated in the fourth extension that after one in-person evaluation, the Act’s remote prescribing requirements “no longer apply to that specific practitioner-patient relationship.” The relationship is prescriber-specific. A visit with a different clinician in your network does not transfer.
- The patient sits with a DEA registrant while your prescriber joins by video. Section 802(54)(B) covers telemedicine conducted while the patient is “being treated by, and in the physical presence of,” a practitioner acting in the usual course of practice, in accordance with state law, and registered in the state where the patient is located. Section 802(54)(A) covers a patient being treated in, and physically located in, a DEA-registered hospital or clinic, with the remote practitioner registered in the patient’s state. Read those conditions before you sign a partner site.
- Covering practitioner. This route is limited to cross-coverage. The covering practitioner acts at the request of a colleague who evaluated the patient in person or through the practice of telemedicine “within the previous 24 months” and who is “temporarily unavailable” (§ 829(e)(2)(C)). It does not let one examiner qualify patients for a whole panel.
One in-person visit meets the statute. It does not prove the prescription is legitimate. The statute says so in § 829(e)(2)(B)(ii), and 21 C.F.R. § 1306.04(a) still governs every prescription.
Document the exam as if someone will ask
Every chart for a never-examined patient should show, for the qualifying encounter: the date, the physical address, the examining practitioner by name, whether the prescriber was physically present or remote, who else was in the room, and which route applied. For route two, record the in-room practitioner’s state and DEA registration status on the date of the visit.
The states that move before DEA does
Eight states already require an in-person exam first or bar a video start for Schedule III, whatever the federal rule says. The state-by-state testosterone table lists them. Those patients should be on your in-person path today.
Two more tie their rule to the federal one.
- Georgia. The written rule, Ga. Comp. R. & Regs. 360-3-.02(5), treats prescribing a controlled substance “based solely on a consultation via electronic means” as unprofessional conduct. On January 8, 2026 the board voted “to extend telemedicine flexibilities until the end of 2026 in alignment with the DEA and HHS.” The rule text did not change. Georgia reverts on January 1, 2027 unless the board acts again, even if DEA extends.
- New York. Under 10 NYCRR § 80.63(d)(1), effective May 21, 2025, no controlled substance may be prescribed before an in-person evaluation, except in listed circumstances. Section 80.63(e) allows telehealth prescribing “when consistent with” DEA rules. When the federal flexibility narrows, New York narrows with it.
Registration, databases and records
DEA registration in each patient state. DEA’s stated position is that a practitioner must register “both in the state in which the practitioner dispenses controlled substances and in the state in which the patient is located” (90 Fed. Reg. 6504, 6512). Route two also depends on it, since § 802(54) conditions the exception on registration in the patient’s state. Location rules for any site that holds stock are separate: see DEA registration by location. Several states also require their own controlled substance registration on top of DEA.
PDMP. New York requires a registry check before every Schedule II, III or IV prescription (N.Y. Pub. Health Law § 3343-a). Other states have their own triggers. Build the check into the prescribing step and save the result to the chart.
Identity and location. Verify identity at the first visit and record where the patient physically is at every visit. Licensure, registration and state rules all turn on it.
Labs and monitoring are protocol items
Your medical director should approve a written protocol that defines the baseline labs required before a first prescription, the diagnostic basis the chart must show, the monitoring labs and their cadence, the findings that pause or stop therapy, and the documentation of each dose change. Clinical specifics belong there, under physician judgment. A chart that shows the lab basis and the follow-up survives review under all three outcomes.
The build sequence
- Pull every active testosterone patient and tag each one: examined in person by the current prescriber, or not.
- Move all new starts in the eight in-person states, and in Georgia, to the in-person path now.
- Pick the in-person route for each state you serve: your own site, or a partner practitioner registered in that state.
- Add the exam fields above to the chart template and backfill them for patients who already qualify.
- Confirm each prescriber’s DEA registration and any state controlled substance registration for every patient state.
- Make PDMP checks, identity verification and location capture required steps in the visit workflow.
- Have the medical director sign the lab and monitoring protocol.
- Watch RIN 1117-AB40 on reginfo.gov and the Federal Register public inspection list weekly through December.
Where MDside stands
Our testosterone visits are synchronous, and we offer them only where state rules allow. In states that require an in-person exam first, we do not start patients by video. MDside is LegitScript certified. We build the in-person path in before launch. That is narrower than a video-only model, and deliberate: it does not depend on a date.
What this means for you
Count your never-examined testosterone patients this week. That number is your exposure on January 1. Choose an in-person route for each state before November, because partner agreements take months and the rule text may arrive with little lead time. Fix the chart fields and registrations in parallel. If you want this built rather than planned, the hormone therapy service describes how we structure it.
Related reading
Frequently asked questions
Can telehealth TRT continue after December 31, 2026?
For patients the prescriber has examined in person at least once, yes, because the Ryan Haight requirement is met for that relationship. For never-examined patients it depends on DEA. As of September 24, 2026, no fifth extension or final special registration rule has been published, and the final rule remains under White House review.
Does an in-person exam by a nurse at a partner clinic count?
Not as the prescriber’s own in-person evaluation, which requires the patient to be in the prescriber’s physical presence. A separate statutory route covers a patient treated in the physical presence of a DEA-registered practitioner acting under state law and registered in the patient’s state, while your prescriber joins remotely. Confirm the in-room clinician meets all of it.
How many in-person visits does federal law require for telehealth testosterone?
One, by the prescribing practitioner, under 21 U.S.C. § 829(e). DEA has said the Act’s remote prescribing requirements then stop applying to that practitioner-patient relationship. State law can require more. New Hampshire requires an annual in-person exam, and Georgia’s rules call for diligent efforts at an annual one.
Which states tie telehealth prescribing of controlled substances to the DEA rule?
Georgia and New York. Georgia’s board extended its flexibility through the end of 2026 by vote, without changing the written rule. New York’s 10 NYCRR § 80.63(e) allows telehealth prescribing only when consistent with DEA rules. Both narrow when the federal flexibility does, and Georgia reverts on January 1, 2027 unless its board acts.
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This is general information, not legal advice. Rules vary by state and change. Confirm your own facts with counsel.