Does federal law override state telehealth restrictions?

**No. The Controlled Substances Act functions as a floor, not a ceiling.** While the DEA permits remote prescribing, practitioners must strictly comply with the state where the patient is located. If a state requires an in-person exam, that state law prevails over the federal waiver.

Can I prescribe Adderall via telehealth in Florida?

**Generally, no—even with the DEA waiver.** Florida Statute 456.47 prohibits prescribing Schedule II controlled substances via telehealth unless strict exceptions are met (e.g., psychiatric disorders, hospice, or hospital treatment). Relying on the federal waiver here is a compliance violation.

Does Alabama require an in-person visit for telehealth?

**Yes, but with a twist.** Alabama requires an in-person encounter within the preceding 12 months, and crucially, licensed medical personnel (RN, PA) must be physically present with the patient during the call. A patient sitting alone at home does not meet this requirement.

Can I use a virtual address for my DEA registration?

**No. The DEA is actively rejecting applications listing virtual mailboxes or UPS Store addresses.** You must list a physical location in the state where you can examine patients and store records.

What is the '50% Rule' in the proposed Special Registration?

**It’s a restriction for 'Advanced' telemedicine registrants.** The proposal states that less than 50% of your total Schedule II prescriptions can be issued via telemedicine. This effectively bans 100% virtual practices for Schedule II drugs.

Do I need to check the PDMP for every telehealth script?

**The proposed rules are moving toward a nationwide mandate.** The goal is to require practitioners to check the PDMP of all 50 states within three years. Currently, you must check the PDMP in the patient's state, your state, and any reciprocity states.

Federal Permission, State Prohibition: The 2026 Telehealth Compliance Trap

Disclaimer: This article is for educational purposes only and does not constitute legal or clinical advice. Telehealth laws change rapidly; always verify requirements with the specific state board of pharmacy or medicine.

The "Green Light" That Isn't

The DEA gave us the green light, but the states are putting up stop signs. The DEA explicitly extended COVID-19 telemedicine flexibilities through December 31, 2025. Effectively, this Ryan Haight Act update 2025 allows practitioners to prescribe controlled substances without a prior in-person evaluation at the federal level.

However, this has created a dangerous false sense of security. In our analysis at Rx Agent, we found that relying solely on federal waivers is a fast track to non-compliance. Why? Because individual states are aggressively enforcing stricter standards.

A Quick Heads-Up for Digital Health Startups

If you are trying to track 50 different state medical boards manually, you are already behind.

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The "Supremacy Clause" in Reverse

In most legal contexts, federal law reigns supreme. In pharmacy practice, the dynamic shifts.

The DEA’s Third Temporary Extension explicitly states that prescribing via telemedicine is subject to a practitioner’s compliance with "state prescribing requirements."

I often explain this to clients as the "Supremacy Clause in reverse." The federal government has essentially said, "We won't arrest you for this, provided your state allows it." If the state doesn't allow it, the federal waiver offers no protection. This creates a trap where a provider is federally compliant but criminally liable at the state level.

Figure: Visualizing the fragmented landscape of telehealth controlled substance laws by state map.

State-Specific Compliance Traps

While ~42 states largely align with DEA flexibilities, roughly eight states have laws mimicking the strict Ryan Haight Act or have erected specific barriers.

1. Florida: The "No-Go" Zone for Stimulants?

Florida presents one of the clearest examples of state law overriding federal flexibility, and understanding the Florida telehealth schedule II exceptions is critical for any digital health company.

The Federal Rule: DEA allows remote prescribing of Schedule IIs (like Adderall).
The Florida Rule: Florida Statute 456.47 generally prohibits it.

While there are narrow exceptions (psychiatric disorders, hospice, nursing homes), if your platform treats chronic non-malignant pain or ADHD without meeting these specific criteria, relying on the federal waiver is a violation.

2. Alabama: The "Physical Presence" Loophole

Alabama focuses on who is in the room. There are virtually no Alabama telehealth exceptions regarding the physical presence of a medical professional.

The Restriction: A prescriber generally cannot issue a controlled substance via telehealth unless there was an in-person encounter in the last 12 months.
The Nuance: This requirement is only met if licensed medical personnel (RN, CRNP, PA) are physically present with the patient during the call.
The Trap: A Licensed Professional Counselor (LPC) or social worker does not count. A Direct-to-Consumer (DTC) model where the patient is alone at home is non-compliant in Alabama.

3. New York & Texas: The New Battlegrounds

New York (May 2025): Finalized a rule requiring an in-person medical evaluation prior to prescribing controlled substances. New York telehealth exceptions are now extremely limited, effectively codifying pre-pandemic standards regardless of federal extensions.
Texas: Adopts a hybrid approach. Texas telehealth exceptions generally apply only if the patient is an established patient seen by the physician within the last 90 days, specifically for chronic pain treatment.

The "Special Registration" Proposal: A False Hope?

On January 17, 2025, the DEA unveiled the proposed "Special Registration" for telemedicine. Many hoped this would preempt state restrictions, but our analysis suggests otherwise.

The catch? It explicitly requires practitioners to obtain a "State Telemedicine Registration" for every state where they treat patients.

The "50% Rule"

For "Advanced" registrants (prescribing Schedule IIs), the proposed rule includes a restrictive cap:

The average monthly number of Schedule II prescriptions issued via telemedicine must be less than 50% of the practitioner's total Schedule II prescriptions.
Result: You cannot run a 100% virtual practice for Schedule IIs. You must have a hybrid model.

Summary of Key Regulatory Conflicts

Issue	Federal (DEA) Stance	State Trap (Examples)
Remote Sched II Prescribing	Allowed through 2025	Florida: Prohibited (unless Psych/Hospice)
In-Person Requirement	Waived	Alabama: Required (Medical personnel must be present)
Start of Care	Telehealth OK	New York: In-person eval required (May 2025 Rule)
Practitioner Location	Flexible	DEA Update: Virtual/UPS addresses are rejected

The PDMP Trap

This is the most overlooked requirement in the proposed rules.

The proposal mandates that within three years, practitioners must check the PDMP of all 50 states before issuing a telemedicine prescription.

Current Reality: No single system allows a seamless 50-state check.
Immediate Requirement: You must check the PDMP of the patient's state, your own state, and any reciprocity states.

Conclusion

The regulatory landscape is fracturing, not unifying. While the federal government pushes for "Special Registrations," states are building their own walls to prevent diversion. A generic, national compliance strategy is no longer sufficient.

Whether you are a solo provider or a digital health startup, you need to verify compliance against specific state statutes before you send that script.