Telehealth TRT Runs on a Rule That Expires December 31, 2026

What the Fourth Temporary Extension Actually Does

The baseline law is the Ryan Haight Online Pharmacy Consumer Protection Act of 2008. It amended the Controlled Substances Act to bar practitioners from prescribing a Schedule II through V controlled substance over the internet without at least one in-person medical evaluation, subject to seven statutory "practice of telemedicine" exceptions codified at 21 U.S.C. 802(54). The seventh of those, at 21 U.S.C. 802(54)(G), is a catch-all: telemedicine conducted under other circumstances that the Attorney General and the Secretary of Health and Human Services jointly determine, by regulation, to be consistent with effective controls against diversion and otherwise consistent with the public health and safety. DEA exercises the Attorney General's authority in this area, which is why every rule built on this exception carries both DEA and HHS.

That catch-all is the hinge. Every pandemic-era telemedicine flexibility for controlled substances has been built on it, which is why each one has to be issued jointly, and why each one has been temporary.

The current version is the Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications. It first became publicly visible on November 10, 2025, when a rule under that name appeared under review at the Office of Management and Budget with its text not yet released, so even its length was unknown at that point. The rule published in the Federal Register on December 31, 2025, effective January 1, 2026 through December 31, 2026.

Mechanically, it is a date change. The rule amends 21 CFR 1307.41 and 42 CFR 12.1 to move the expiration of the existing flexibility from December 31, 2025 to December 31, 2026. It does not expand the flexibility, tighten it, or add new conditions. What it preserves is the ability of a DEA-registered practitioner to prescribe Schedule II through V controlled medications via an audio-video telemedicine encounter without a prior in-person evaluation, plus audio-only encounters for Schedule III through V narcotic medications approved by the FDA for maintenance and withdrawal management treatment of opioid use disorder.

Here is the full sequence of temporary rules, using Federal Register publication dates:

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Four rules. Four expiration dates. No permanent framework yet.

Why Testosterone Sits Squarely Inside This Rule

Testosterone is a Schedule III controlled substance. Congress placed anabolic steroids, defined by reference to substances chemically and pharmacologically related to testosterone, into Schedule III of the Controlled Substances Act through the Anabolic Steroids Control Act of 1990, and that classification has held since.

That single fact is the reason this rulemaking matters to the testosterone market and not to most of the rest of the peptide and optimization world. Because testosterone is scheduled, the Ryan Haight in-person evaluation requirement applies to it by default, and the temporary telemedicine flexibility is the exception that switches that requirement off. Remove the flexibility with no replacement, and the default statutory rule returns for patients who have never had a qualifying in-person evaluation with the prescriber.

It is worth being precise about the boundary here, because it is commonly blurred. Most research peptides are not controlled substances at all, so DEA scheduling rules and this telemedicine flexibility are simply not the governing law for them. Our clinic-facing piece on [telehealth peptide prescribing and state licensing rules](/blog/clinic-telehealth-peptide-prescribing) makes that same distinction, and this article does not contradict it: the DEA telemedicine extension is about controlled substances, and testosterone is one of the very few compounds in this space that qualifies. State medical licensure is a separate legal layer that applies regardless, and it does not expire on December 31, 2026.

Two more practical details about Schedule III that shape what a lapse would look like. Under 21 CFR 1306.22, a Schedule III prescription authorized for refills may be refilled up to five times, and may not be filled or refilled more than six months after the date it was issued, so an existing valid prescription does not evaporate the moment a rule changes. And DEA registration attaches to the practitioner at a registered physical location, with separate registration generally required in each state where the practitioner maintains a practice location, which means a clinic's ability to serve you can change for reasons that have nothing to do with your labs.

The Permanent Replacement Has Not Arrived

On January 17, 2025, DEA published a proposed rule titled Special Registrations for Telemedicine and Limited State Telemedicine Registrations (Docket No. DEA-407, RIN 1117-AB40). It would create a durable framework to replace the temporary extensions, built around three new registration types.

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Testosterone, as a Schedule III drug, would fall under the first and broadest tier. The proposal also attached conditions that would meaningfully change how a national telehealth clinic operates, including a separate State Telemedicine Registration in each state where the practitioner prescribes (with proposed fees of $50 for clinician practitioners and $888 for platform practitioners), mandatory prescription drug monitoring program checks that would expand to all U.S. jurisdictions after three years, a physical address as the registered location, a requirement that the practitioner be physically located in the United States when issuing the prescription, and heightened recordkeeping and electronic prescribing requirements.

The comment period closed at 11:59 p.m. ET on March 18, 2025, and the docket drew extensive public comment, including formal objections from hospital and clinician organizations arguing the registration process would be burdensome and administratively inefficient. As of early August 2026, no final rule has published, and no fifth temporary extension has published either. The proposal remains a proposal.

Four Extensions Deep: What the Pattern Does and Does Not Tell You

The extension itself states only that extending the flexibilities gives DEA additional time to finalize and implement effective regulations balancing access to care against safeguards against diversion. It sets no deadline for that final rule. The Unified Regulatory Agenda has listed November 2026 as a target month for action on the special registration rule, which would land roughly six weeks before the flexibility lapses.

The longer history is the more honest signal. A special registration pathway has been contemplated since the Ryan Haight Act itself in 2008. The SUPPORT for Patients and Communities Act of 2018 then required DEA to promulgate final special registration regulations by October 2019. That deadline came and went, and the first proposal resembling the current framework did not appear until January 2025. This rulemaking has a documented multi-year record of missed target dates.

Two readings of the current pattern are both defensible, and it would be dishonest to present either as a forecast.

What is not in dispute: the operative rule has a hard end date of December 31, 2026, the replacement has not been finalized, and no one outside the agencies knows which way this resolves. Treat anyone selling certainty about January 2027, in either direction, with skepticism.

The question also resolves in public, in exactly two places. A final rule under RIN 1117-AB40 would publish in the Federal Register, and any fifth temporary extension would publish there as well. Watching those two channels is more reliable than watching the commentary around them, and considerably more reliable than watching clinic marketing, which has an obvious incentive to project confidence.

What to Track, and What Not to Change

Nothing about your prescription, your dosing, or your monitoring schedule changes because of a Federal Register expiration date. The flexibility is in force today. Decisions about whether, how, and with whom you receive testosterone therapy are clinical and legal decisions that belong to you and your licensed prescriber, and this article is not a reason to alter any of them.

What is genuinely actionable is administrative, and it is worth doing regardless of how the rulemaking lands. If your prescriber, your platform, or your state situation changes for any reason at all, the thing that determines whether a new clinician can pick up your care efficiently is whether you can hand them a clean, dated history. Most people cannot. Their labs live in three portals, their dosing history lives in memory, and their baseline draw from two years ago is a PDF in an email attachment nobody can find. Portable records are the asset here. Regulatory uncertainty just makes the case for them unusually concrete.

None of the following is a recommendation to test, treat, or change anything. It is a description of what is commonly monitored in testosterone therapy so you can organize your own record and review it with your provider.

Beyond the biomarkers, the records that actually travel are these: the date and result of every draw, which laboratory ran it and in what units, your baseline panel from before therapy started (the single most commonly lost document in this category), your dosing history with dates and any changes, and the name of the prescriber and clinic associated with each period. Draw timing relative to your dose matters for interpretation, which is covered in our [blood work timing guide](/blog/peptide-blood-work-timing-guide), and if you are building a broader picture, the [longevity blood panel](/blog/longevity-blood-panel) walks through what a wider baseline typically includes.

The tracking work itself is unglamorous and durable. Log every draw under consistent conditions, keep units and lab names attached to each result, preserve the baseline, and keep the dosing history dated. If your care continues exactly as it is, you have a better record than you had before. If anything changes, for regulatory reasons or the far more ordinary reasons that providers change, you can hand the next clinician a real history instead of a shrug. MyProtocolStack organizes and visualizes that record. It does not interpret it, and it is not a substitute for your prescriber's judgment.

[Keep your lab history, baseline panel, and dosing record in one place you control with MyProtocolStack.](/auth/login?mode=signup)

The Continuity Conversation Coaches Can Run This Quarter

Coaches, trainers, and non-clinical practitioners cannot and should not advise anyone on a controlled substance. But there is a completely appropriate, entirely non-medical conversation available here, and this quarter is the natural time to run it with any client on telehealth-prescribed testosterone.

It has two parts.

First, ask the clinic a factual question. Something close to: "What is your contingency plan if the DEA telemedicine flexibility is not renewed or replaced by December 31, 2026?" This is a business continuity question, not a medical one. A clinic with a real answer will describe in-person options, licensed partners in your state, or how they are tracking the rulemaking. A clinic that has never considered it has told you something useful about how it is run. Either way, the client learns something from their own provider rather than from a coach.

Second, export the records now, while the relationship is calm. Every lab result with dates and units, the pre-therapy baseline, the dosing history, and the clinic's contact and prescriber information. Requesting records is routine, patients are entitled to their own health information, and it is far easier to do during an ordinary check-in than during a scramble. For clinic operators reading this from the other side of the table, our piece on [biomarker data management](/blog/clinic-biomarker-data-management) covers the operational version of the same problem.

The deliverable in both cases is a portable, dated record. That is a documentation outcome, not a clinical one, which is exactly why a coach can own it.

Frequently Asked Questions

Can I still get testosterone prescribed online in 2027?

Nobody knows yet, and anyone claiming certainty is guessing. The rule that currently permits telehealth prescribing of testosterone without a prior in-person exam, the fourth temporary DEA and HHS extension of COVID-era telemedicine flexibilities, is effective January 1, 2026 through December 31, 2026. Access into 2027 depends on DEA either finalizing its permanent special registration framework or issuing a fifth extension. As of early August 2026, neither had happened. The Unified Regulatory Agenda has listed November 2026 as a target month for action on the final rule, but this rulemaking has missed target dates repeatedly, including a statutory October 2019 deadline set by Congress in the SUPPORT Act of 2018. Questions about your specific care should go to your licensed prescriber.

What exactly does the fourth temporary extension do?

It amends 21 CFR 1307.41 and 42 CFR 12.1 to move the expiration date of the existing telemedicine flexibility from December 31, 2025 to December 31, 2026. The rule first became publicly visible on November 10, 2025, when it appeared under review at the Office of Management and Budget without released text, and it published in the Federal Register on December 31, 2025, effective January 1, 2026. It preserves telemedicine prescribing of Schedule II through V controlled medications without a prior in-person medical evaluation, plus audio-only encounters for Schedule III through V narcotic medications approved by the FDA for maintenance and withdrawal management treatment of opioid use disorder. It does not expand or tighten the flexibility, it only changes the date.

Why does the DEA rule affect testosterone but not most peptides?

Because testosterone is a Schedule III controlled substance, placed there along with other anabolic steroids by the Anabolic Steroids Control Act of 1990. The Ryan Haight Act of 2008 requires at least one in-person medical evaluation before a controlled substance is prescribed over the internet, subject to seven statutory exceptions at 21 U.S.C. 802(54), and the temporary flexibility operates through the catch-all exception at 802(54)(G), which requires a joint determination by the Attorney General and the Secretary of Health and Human Services. Most research peptides are not controlled substances at all, so DEA scheduling and this telemedicine flexibility are not the governing law for them. State medical licensure, by contrast, applies to telehealth prescribing regardless of scheduling and does not expire at the end of 2026.

What is the permanent replacement rule and what would it change?

On January 17, 2025, DEA published a proposed rule, Special Registrations for Telemedicine and Limited State Telemedicine Registrations (Docket No. DEA-407, RIN 1117-AB40), creating three registration types: a Telemedicine Prescribing Registration covering Schedule III through V, an Advanced Telemedicine Prescribing Registration covering Schedule II through V for specialized clinicians, and a Telemedicine Platform Registration for online platforms. Testosterone would fall under the first tier. The proposal also included a separate state telemedicine registration in each state where a practitioner prescribes, with proposed fees of $50 for clinician practitioners and $888 for platform practitioners, prescription drug monitoring program checks expanding to all U.S. jurisdictions after three years, a physical registered address, and heightened recordkeeping and electronic prescribing requirements. Comments closed March 18, 2025 and no final rule had published as of early August 2026.

What should I actually do about this right now?

Nothing clinical. Do not start, stop, or change a prescription because of a regulatory deadline, and take any questions about your therapy to your licensed prescriber. What is worth doing is administrative and useful either way: ask your telehealth clinic what its contingency plan is if the flexibility is not renewed or replaced, and export your records while the relationship is calm. That means every lab result with its date, units, and laboratory name, your pre-therapy baseline panel, your full dosing history with dates, and the prescriber and clinic associated with each period. Portable, dated records are what let a new clinician pick up your care efficiently, for regulatory reasons or the far more common ordinary ones.

Sources

1. Federal Register, "Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications," published December 31, 2025, effective January 1, 2026 through December 31, 2026. https://www.federalregister.gov/documents/2025/12/31/2025-24123/fourth-temporary-extension-of-covid-19-telemedicine-flexibilities-for-prescription-of-controlled

2. U.S. Government Publishing Office, full text of the Fourth Temporary Extension, 90 FR 61301, December 31, 2025. https://www.govinfo.gov/content/pkg/FR-2025-12-31/html/2025-24123.htm

3. Drug Enforcement Administration, "DEA Extends Telemedicine Flexibilities to Ensure Continued Access to Care," December 31, 2025. https://www.dea.gov/press-releases/2025/12/31/dea-extends-telemedicine-flexibilities-ensure-continued-access-care

4. U.S. Department of Health and Human Services, "HHS and DEA Extend Telemedicine Flexibilities for Prescribing Controlled Medications Through 2026." https://www.hhs.gov/press-room/dea-telemedicine-extension-2026.html

5. Federal Register, "Special Registrations for Telemedicine and Limited State Telemedicine Registrations," proposed rule published January 17, 2025, Docket No. DEA-407, RIN 1117-AB40. https://www.federalregister.gov/documents/2025/01/17/2025-01099/special-registrations-for-telemedicine-and-limited-state-telemedicine-registrations

6. Foley and Lardner, "DEA Unveils Long-Overdue Special Registration for Telemedicine in Proposed Rule," January 2025, for the three registration tiers, proposed fees, and PDMP requirements. https://www.foley.com/insights/publications/2025/01/dea-special-registration-telemedicine-proposed-rule/

7. Alliance for Connected Care, "DEA Prescribing of Controlled Substances," rulemaking status tracker including Unified Agenda target dates and the SUPPORT Act deadline history. https://connectwithcare.org/dea-prescribing-of-controlled-substances/

8. eCFR, 21 CFR 1307.41, "Temporary extension of certain COVID-19 telemedicine flexibilities for prescription of controlled medications." https://www.ecfr.gov/current/title-21/chapter-II/part-1307/section-1307.41

9. eCFR, 21 CFR 1306.22, "Refilling of prescriptions," for Schedule III refill limits. https://www.ecfr.gov/current/title-21/chapter-II/part-1306/subject-group-ECFRe4ae2bfb4eae102/section-1306.22

10. Federal Register, "Second Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications," published October 10, 2023, for the sequence and scope of the first two temporary rules. https://www.federalregister.gov/documents/2023/10/10/2023-22406/second-temporary-extension-of-covid-19-telemedicine-flexibilities-for-prescription-of-controlled

*MyProtocolStack is a tracking and education tool, not medical advice, legal advice, diagnosis, or treatment, and you should always consult a qualified healthcare professional before making any changes to your health protocol.*