What a state requires before a first online prescription

Two states, two different tests

These are state professional-practice rules, distinct from the federal provisions on prescription validity. They bind a licensee in that state, and a prescriber may be subject to both layers at once.

Virginia builds its rule around a defined relationship. A prescription shall be issued only to persons with whom the practitioner has a bona fide practitioner-patient relationship, and the statute then defines what such a relationship requires.

California builds its rule around a defined act. Prescribing, dispensing, or furnishing dangerous drugs without an appropriate prior examination and a medical indication constitutes unprofessional conduct.

The difference in framing has consequences. Virginia's version is a condition on issuing the prescription at all; California's is a disciplinary standard aimed at the prescriber's licence.

Virginia adds a purpose test alongside the relationship test. A prescription shall only be issued for a medicinal or therapeutic purpose in the usual course of treatment or for authorised research, and a prescription not issued in the usual course of treatment or for authorised research is not a valid prescription.

What Virginia's relationship requires

The Virginia definition has four limbs, and the statute lists them in order.

A bona fide practitioner-patient relationship exists if the practitioner has obtained or caused to be obtained a medical or drug history of the patient; provided information to the patient about the benefits and risks of the drug being prescribed; performed or caused to be performed an appropriate examination of the patient; and initiated additional interventions and follow-up care, if necessary, especially if a prescribed drug may have serious side effects.

The examination limb carries its own definition of what will do. It may be performed either physically or by the use of instrumentation and diagnostic equipment through which images and medical records may be transmitted electronically.

It also carries a limit on who may perform it. Except in cases involving a medical emergency, the examination shall be performed by the practitioner prescribing the controlled substance, a practitioner who practises in the same group as that practitioner, or a consulting practitioner.

The fourth limb is the one most easily overlooked from the outside. Initiating additional interventions and follow-up care where necessary is written into the definition of the relationship, which makes what happens after the prescription part of the test rather than an optional extra.

California addresses the video question directly

The most-asked question about online prescribing is whether a live conversation is required, and California answers it in a single sentence inside its unprofessional conduct provision.

An appropriate prior examination does not require a synchronous interaction between the patient and the licensee and can be achieved through the use of telehealth, including, but not limited to, a self-screening tool or a questionnaire, provided that the licensee complies with the appropriate standard of care.

The sentence does two things at once. It removes any implication that live audio or video is mandatory in California for the examination to count, and it makes the whole allowance conditional on the standard of care.

The proviso is the operative half. A questionnaire is named as capable of achieving an appropriate prior examination; whether it did so in a given case is measured against the standard of care rather than against the format.

The same section lists exceptions in which a licensee shall not be found to have committed unprofessional conduct under it, including a designated practitioner serving in the absence of the patient's own practitioner and prescribing only as necessary to maintain the patient until that practitioner returns, in any case no longer than seventy-two hours.

What Virginia adds for telemedicine

Virginia legislates the telemedicine case separately rather than leaving it to the general definition, and the conditions are cumulative.

A practitioner who has established a bona fide practitioner-patient relationship may prescribe Schedule II through VI controlled substances to that patient via telemedicine if the prescribing complies with federal requirements for the practice of telemedicine and, for Schedule II through V, the prescriber maintains a practice at a physical location in the Commonwealth, or is able to make appropriate referral of patients to a licensed practitioner located in the Commonwealth in order to ensure an in-person examination when required by the standard of care.

That physical-location-or-referral condition is a structural requirement about the prescriber's practice, not about the individual encounter. It asks whether there is somewhere in the state a patient can be sent.

Virginia separately allows the relationship itself to be established by telemedicine, through face-to-face interactive, two-way, real-time communications services or store-and-forward technologies, when a list of lettered conditions is met. Among them: the patient has provided a medical history available for review; the prescriber obtains an updated medical history at the time of prescribing; the prescriber makes a diagnosis at the time of prescribing; and the prescriber conforms to the standard of care expected of in-person care as appropriate to the patient's age and presenting condition, including where that standard requires diagnostic testing and a physical examination, which may be carried out using peripheral devices appropriate to the condition.

The remaining conditions are about the prescriber's standing and the records. The prescriber must be actively licensed in the Commonwealth and authorised to prescribe; must, where the patient is a member of a health plan, have been credentialed by that plan as a participating provider; must provide patient records in a timely manner on request; and the establishment of the relationship by telemedicine must be consistent with the standard of care where that standard does not require an in-person examination for diagnosis, and consistent with federal law and regulations and any waiver of them.

The pharmacist's duty, and the penalty aimed at the seller

Virginia does not leave the relationship question entirely with the prescriber. It gives the dispensing pharmacist a role and a trigger.

No prescription shall be filled unless a bona fide practitioner-patient-pharmacist relationship exists, which the statute says exists where a practitioner prescribes and a pharmacist dispenses controlled substances in good faith to a patient for a medicinal or therapeutic purpose within the course of professional practice.

The trigger is specific. In cases in which it is not clear to a pharmacist that a bona fide practitioner-patient relationship exists between a prescriber and a patient, the pharmacist shall contact the prescribing practitioner or their agent and verify the identity of the patient and the name and quantity of the drug prescribed.

California points its enforcement at the seller as well as the prescriber, and it does so in a section written for the internet. No person or entity may prescribe, dispense, or furnish, or cause to be prescribed, dispensed, or furnished, dangerous drugs or dangerous devices on the internet for delivery to any person in the state without an appropriate prior examination and medical indication, except as authorised by the section that permits the asynchronous examination.

The consequences are set out in figures and in a referral. A violation may subject the person or entity to a fine of up to twenty-five thousand dollars per occurrence under a citation issued by the board, or a civil penalty of twenty-five thousand dollars per occurrence, and the Attorney General may bring an action to enforce the section and collect them. Where the person or entity is not a resident of the state, a violation shall, if applicable, be reported to their appropriate professional licensing authority.

Sources

Each document below is named as it names itself, with the date printed on that document rather than the day it was read.

1. Code of Virginia section 54.1-3303, Prescriptions to be issued and drugs to be dispensed for medical or therapeutic purposes only, including the bona fide practitioner-patient relationship and the telemedicine conditions — Virginia Law, Virginia General Assembly, 2025
2. California Business and Professions Code section 2242, prescribing without an appropriate prior examination and medical indication as unprofessional conduct — California Legislative Information, California Legislature, October 2019
3. California Business and Professions Code section 2242.1, prohibiting prescribing, dispensing or furnishing dangerous drugs on the internet for delivery into the state without an appropriate prior examination — California Legislative Information, California Legislature, January 2016