Do I need an in-person exam for Topamax in Pennsylvania?

If you’re struggling with Binge Eating Disorder (BED), you might be wondering whether you can access treatment through telehealth—and whether it’s legal to get medications like Topamax or Wellbutrin prescribed online. The short answer is yes. As of 2026, telehealth has become a legitimate, accessible pathway for BED treatment across the United States, with clear regulations that protect both patient safety and access to care.

This comprehensive guide will walk you through everything you need to know about getting BED medications through telehealth, including the legal landscape, what to expect during your evaluation, and how to ensure you’re receiving safe, quality care.

Understanding Telehealth for Binge Eating Disorder Treatment

Binge Eating Disorder affects millions of Americans, characterized by recurrent episodes of eating large quantities of food in a short period, feeling out of control during these episodes, and experiencing distress afterward—without the compensatory purging behaviors seen in bulimia. While therapy remains the gold standard treatment, medications can play an important supportive role for many patients.

The pandemic permanently transformed healthcare delivery, and telehealth for mental health and eating disorder treatment has emerged as a proven, effective model. Today’s telehealth platforms connect patients with licensed psychiatrists, psychiatric nurse practitioners, and other qualified providers who can evaluate, diagnose, and treat BED—all from the comfort of your home.

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The Legal Framework: Federal Rules for Telehealth Prescribing

Non-Controlled Medications: Fully Permitted

Here’s the crucial distinction that clears up most confusion: medications commonly prescribed for BED—including topiramate (Topamax) and bupropion (Wellbutrin)—are not controlled substances. This means they fall outside the stricter regulations of the Ryan Haight Act, which governs controlled substance prescribing via telemedicine.

For non-controlled medications, there has never been a federal requirement for an in-person examination before prescribing via telehealth. As long as your provider is licensed in your state and follows the standard of care, they can legally prescribe these medications after a proper telehealth evaluation.

Controlled Substances: A Different Story

It’s worth noting that the only FDA-approved medication specifically for BED is lisdexamfetamine (Vyvanse), which is a Schedule II controlled substance. The rules for prescribing controlled substances via telehealth are more restrictive and currently operate under temporary COVID-era flexibilities extended through December 31, 2026. Most reputable telehealth platforms focus on non-controlled medication options for BED to avoid the regulatory complexity and safety concerns associated with stimulant prescribing online.

State-by-State Variations: What You Need to Know

While federal law provides the baseline, individual states can impose additional requirements. The good news is that most states have embraced telehealth permanently and removed barriers that existed before 2020.

States with No In-Person Requirements

The majority of states—including California, New York, Texas, Florida, Delaware, Michigan, Wisconsin, and South Carolina—do not require an in-person visit before prescribing non-controlled medications via telehealth. In these states, a comprehensive video consultation serves as the qualifying examination.

California even goes further, with 2025 legislation (AB 1503) explicitly allowing ‘good faith exams’ to be conducted via asynchronous telehealth (like detailed online questionnaires) when appropriate to the standard of care.

States with Periodic In-Person Requirements

A smaller number of states require some form of in-person contact for ongoing telehealth care:

• Alabama requires an in-person visit within 12 months if you’ve had more than four telehealth visits for the same condition. However, this can often be satisfied by seeing any healthcare provider in person (not necessarily your telehealth prescriber).

• Georgia requires providers to attempt an annual in-person examination for continuing telemedicine patients, though initial evaluations can be done entirely via telehealth if the technology allows for an adequate assessment.

• New Hampshire allows telehealth prescribing to begin remotely but requires at least one in-person visit within 12 months for patients on certain medications (this primarily affects controlled substances, but providers may apply it broadly).

These requirements are designed to ensure continuity of care rather than create barriers, and most telehealth platforms operating in these states have systems in place to help patients meet these obligations through partner clinics or referrals to local providers.

Medications Commonly Prescribed for BED via Telehealth

Topiramate (Topamax)

Topiramate is an anticonvulsant medication FDA-approved for seizures and migraine prevention, but commonly used off-label for BED. Research suggests it can help reduce binge frequency and support weight management in some patients.

Key considerations:

• Starting dose: Typically low (25mg) with gradual titration to minimize side effects
• Common side effects: Cognitive effects (‘brain fog’), tingling in extremities, taste changes, kidney stones
• Pregnancy warning: Topiramate carries significant risks during pregnancy, including increased risk of cleft palate and other birth defects. Women of childbearing age should use effective contraception
• Discontinuation: Must be tapered gradually to avoid seizure risk
• Monitoring: Regular follow-ups to assess cognitive effects, weight, and metabolic parameters

Bupropion (Wellbutrin)

Bupropion is an antidepressant FDA-approved for depression and smoking cessation, with off-label use for BED showing promise in reducing binge episodes.

Key considerations:

• Black box warning: Like all antidepressants, carries a warning about increased suicidal thoughts in young adults under 25—close monitoring is essential
• Contraindications: Cannot be used in patients with current or past bulimia or anorexia nervosa due to seizure risk; also contraindicated in seizure disorders
• Seizure risk: Increases with higher doses, alcohol use, or abrupt discontinuation of sedatives
• Benefits: May also help with co-occurring depression and has a lower risk of weight gain compared to other antidepressants
• Monitoring: Blood pressure checks, mood monitoring, and assessment of alcohol use

Understanding Off-Label Use

Both medications are used ‘off-label’ for BED, meaning they’re prescribed for a condition other than what the FDA originally approved them for. This is completely legal and extremely common in medicine—estimates suggest one in five prescriptions is for an off-label use. The practice is based on clinical research, expert consensus, and individual patient needs.

Your telehealth provider should explain why they’re recommending an off-label medication, discuss the supporting evidence, and document your informed consent. At Klarity Health, our providers take time during consultations to ensure you understand your treatment options, including both the potential benefits and risks of any medication prescribed.

What to Expect During Your Telehealth Evaluation

The Initial Assessment

A legitimate telehealth evaluation for BED should be comprehensive—typically 30 to 45 minutes for an initial consultation. Your provider will ask detailed questions about:

• Eating patterns: Frequency of binge episodes, typical quantities, time of day, triggers
• Emotional components: Feelings during and after binges, distress level, sense of control
• Duration: How long you’ve experienced these symptoms (DSM-5 criteria require at least weekly binges for three months)
• Associated behaviors: Whether you engage in compensatory behaviors like purging, excessive exercise, or fasting
• Medical history: Other health conditions, medications, prior treatments, family history
• Mental health: Depression, anxiety, trauma, substance use
• Safety screening: Suicidal thoughts, eating disorder complications, substance use

Your provider will also verify that you meet DSM-5 diagnostic criteria for BED, which include:

• Recurrent episodes of eating significantly more food than normal in a discrete period
• Feeling a lack of control during these episodes
• Episodes associated with at least three of the following: eating rapidly, eating until uncomfortably full, eating when not physically hungry, eating alone due to embarrassment, feeling disgusted or guilty afterward
• Marked distress about binge eating
• Binge eating at least once weekly for three months
• Absence of regular compensatory behaviors (which would suggest bulimia nervosa instead)

Documentation and Consent

Before prescribing, your provider will:

• Verify your identity and location to ensure they’re licensed in your state
• Obtain informed consent for telehealth services and for any medication prescribed
• Document the evaluation in a secure electronic health record
• Discuss treatment alternatives, including psychotherapy, nutrition counseling, and support groups
• Create a treatment plan with clear goals and follow-up schedule

This documentation protects both you and the provider, ensuring there’s a clear record of appropriate care.

What Happens Next

If medication is appropriate, your provider will:

• Electronically send your prescription to a pharmacy of your choice
• Provide clear instructions on how to take the medication, including dose titration if applicable
• Discuss potential side effects and what to do if you experience them
• Schedule follow-up appointments (typically within 2-4 weeks initially)
• Provide contact information for urgent questions or concerns

Provider Credentials: Who Can Prescribe BED Medications via Telehealth?

Physicians (MD/DO)

Medical doctors and doctors of osteopathic medicine can prescribe these medications in all 50 states via telehealth, provided they’re licensed in the state where you’re located during the consultation.

Nurse Practitioners (NPs)

Nurse practitioners are increasingly important in expanding access to mental health and eating disorder treatment. As of 2025, approximately 34 states (plus DC) grant nurse practitioners full practice authority, meaning they can evaluate patients and prescribe medications independently without physician oversight.

States with full NP practice authority include New York, California, New Hampshire, Connecticut, Oregon, Washington, and—as of 2025—Michigan, Wisconsin, Kansas, and Louisiana.

In states without full practice authority (such as Texas, Florida, Georgia, and Alabama), NPs can still prescribe non-controlled medications for BED, but they must work under a collaborative agreement with a physician. This is typically a behind-the-scenes arrangement that doesn’t affect your care experience—you’ll primarily interact with the NP, but a physician reviews their protocols and is available for consultation.

Physician Assistants (PAs)

Physician assistants can prescribe medications in all states but generally require some level of physician supervision or collaboration. The specific requirements vary by state, but PAs are qualified to treat BED and prescribe the non-controlled medications discussed here.

At Klarity Health, we work with a diverse team of qualified providers—including psychiatrists, psychiatric nurse practitioners, and physician assistants—all licensed in your state and experienced in treating eating disorders and related conditions.

Red Flags: Identifying Unsafe Telehealth Practices

The telehealth boom has unfortunately attracted some bad actors. Here are warning signs of substandard or potentially unsafe telehealth services:

Guaranteed Prescriptions

Any service that promises a prescription before evaluation is a red flag. Legitimate providers cannot guarantee medication without first assessing whether it’s clinically appropriate and safe for you.

Minimal Evaluation

If your ‘evaluation’ consists of five minutes and a few checkbox questions, that’s inadequate. A proper BED assessment requires detailed exploration of your symptoms, history, and circumstances.

Skipping Safety Screening

Providers who don’t ask about contraindications (like history of seizures, eating disorders with purging, pregnancy) are cutting dangerous corners.

Controlled Substance Focus

Be very wary of telehealth services that heavily promote or readily prescribe controlled substances like stimulants. While there are legitimate uses, the regulatory scrutiny on telehealth stimulant prescribing has intensified following high-profile cases like the Done Global indictment in 2024, where executives were charged with running an illegal Adderall distribution scheme disguised as ADHD telehealth.

No Licensed Providers

Some websites claim to connect you with ‘health professionals’ without specifying credentials or state licensure. Always verify that you’re seeing an actual MD, DO, NP, or PA licensed in your state.

Selling Medications Directly

Legitimate telehealth services send prescriptions to regular pharmacies (retail or licensed mail-order). If a site wants to sell you the medication directly without involving a pharmacy, that’s illegal in most states and potentially dangerous.

Insurance, Pricing, and Access

Insurance Coverage

Most major health insurance plans now cover telehealth visits at the same rate as in-person visits, thanks to pandemic-era policies that have been extended or made permanent. This includes:

• Medicare (extended telehealth coverage through at least 2026)
• Medicaid (varies by state, but most have expanded telehealth)
• Commercial insurance (most major carriers cover telehealth)

Coverage for the medications themselves depends on your pharmacy benefit. Topiramate and bupropion are both generic medications, which are typically well-covered with low copays.

Cash-Pay Options

For those without insurance or who prefer not to use it, many telehealth platforms offer cash-pay pricing. Klarity Health accepts both insurance and self-pay, with transparent pricing so you know the cost upfront. Cash-pay consultations typically range from $79-$150 for initial visits and $49-$99 for follow-ups, though prices vary by provider and platform.

The medications themselves are generally affordable as generics—typically $10-$40 per month without insurance, depending on dose and pharmacy.

Appointment Availability

One major advantage of telehealth is availability. While wait times to see an in-person psychiatrist or eating disorder specialist can stretch to months in many areas, telehealth platforms often have appointments available within days or even the same day. Klarity Health maintains a robust network of providers to minimize wait times and ensure you can access care when you need it.

The Role of Therapy and Comprehensive Care

While medication can be helpful, it’s important to understand that medication alone is rarely sufficient for BED. Research consistently shows the best outcomes come from combining medication with evidence-based psychotherapy.

Cognitive Behavioral Therapy (CBT)

CBT for BED specifically targets the thoughts and behaviors that maintain binge eating patterns. It has the strongest evidence base of any treatment and is considered first-line therapy.

Nutritional Counseling

Working with a registered dietitian who specializes in eating disorders can help you develop a healthier relationship with food, establish regular eating patterns, and reduce dietary restriction that often triggers binges.

Support Groups

Peer support through groups like Overeaters Anonymous or specialized BED support groups can provide community and accountability.

Integrated Treatment

The most effective telehealth platforms recognize that BED requires multidisciplinary care. While you might initially see a prescriber, a comprehensive treatment plan should include referrals or connections to therapy, nutrition support, and other services as needed.

Prescription Monitoring and Ongoing Care

Refill Policies

Because topiramate and bupropion aren’t controlled substances, providers can typically prescribe them with multiple refills (up to 6-12 months in most states). However, you should expect regular follow-up appointments, especially when starting treatment.

A typical schedule might include:

• Initial evaluation and prescription
• Follow-up at 2 weeks to assess tolerance and side effects
• Monthly visits for the first 3 months
• Quarterly visits once stable

Monitoring Requirements

While state Prescription Monitoring Programs (PMPs) track controlled substance prescriptions, they generally don’t include non-controlled medications like those used for BED. However, your provider may still:

• Review your medication history to check for interactions
• Request recent lab work (thyroid function, metabolic panel) to rule out other causes of symptoms
• Monitor specific parameters based on the medication (weight, blood pressure, cognitive function)

When In-Person Care Is Needed

Even with telehealth as your primary care model, certain situations warrant in-person evaluation:

• Severe medical complications from BED (unstable vital signs, severe electrolyte abnormalities)
• Pregnancy or major medical conditions requiring physical examination
• Lack of response to multiple treatments, suggesting need for higher level of care
• Development of concerning symptoms that can’t be adequately assessed remotely

Good telehealth providers know their limitations and will refer you for in-person care when appropriate.

Special Populations and Considerations

Pregnancy and Breastfeeding

Topiramate is contraindicated in pregnancy due to significant risk of birth defects, particularly cleft palate. If you’re pregnant, planning pregnancy, or not using reliable contraception, topiramate is not an appropriate choice.

Bupropion has less clear-cut pregnancy data but is generally avoided when possible. If you become pregnant while on either medication, contact your provider immediately—don’t stop abruptly without guidance.

For pregnant individuals with BED, the focus shifts entirely to therapy and nutritional counseling, with medication generally reserved for postpartum if needed.

Adolescents

While BED can develop in adolescence, prescribing practices for minors require extra caution. Many telehealth platforms restrict services to adults (18+). Adolescents with BED typically need specialized eating disorder treatment programs rather than online medication management.

Co-Occurring Conditions

BED frequently occurs alongside:

• Depression and anxiety
• ADHD
• Substance use disorders
• Other eating disorders (past or current)

Your telehealth provider should screen for these conditions and adjust treatment accordingly. For example, if you have both BED and depression, bupropion might address both conditions. If you have ADHD and BED, the treatment approach becomes more complex and may require referral to a specialist.

Recent Policy Updates and What They Mean for You

2025-2026 Regulatory Landscape

The telehealth regulatory environment continues to evolve:

Federal: The DEA extended COVID-era flexibilities for controlled substance prescribing through December 31, 2026, while working on permanent rules. This doesn’t directly affect non-controlled BED medications, but it signals continued federal support for telehealth access.

State Level: 2025 saw several states modernize their telehealth laws:

• New Hampshire (SB 252) explicitly allowed telehealth prescribing even for Schedule II-IV medications with periodic in-person follow-up
• Wisconsin and Michigan granted nurse practitioners full practice authority, expanding the provider pool
• California (AB 1503) clarified that asynchronous telehealth can constitute an appropriate exam
• New York implemented new rules requiring in-person exams for controlled substances (effective 2025) but left non-controlled medications unaffected

These changes generally expand access while adding safety guardrails for higher-risk medications.

What’s on the Horizon

Watch for:

• DEA’s final rule on permanent telehealth prescribing standards (expected by end of 2026)
• Additional states considering nurse practitioner full practice authority
• Potential federal legislation to standardize interstate telehealth licensing
• Continued insurance coverage policy extensions

The trend is clearly toward maintaining and expanding telehealth access, with enhanced oversight to prevent abuse while protecting legitimate care.

Taking the Next Step: Getting Started with Telehealth for BED

If you’re considering telehealth treatment for Binge Eating Disorder, here’s how to move forward safely and effectively:

1. Choose a Reputable Platform

Look for services that:

• Clearly list provider credentials and state licensing
• Conduct thorough evaluations (30+ minutes)
• Offer transparent pricing
• Provide clear privacy policies (HIPAA-compliant)
• Include follow-up care, not just one-time prescriptions
• Have a multi-disciplinary approach (or referrals to therapy)

2. Prepare for Your Appointment

Before your evaluation:

• Write down your symptoms, including frequency and severity of binges
• List all current medications and supplements
• Note any medical conditions or past treatments
• Prepare questions about treatment options
• Ensure you have a private, quiet space for your video visit

3. Be Honest and Thorough

The quality of care you receive depends on the information you provide. Share openly about:

• The full extent of your symptoms
• Any purging or compensatory behaviors
• Mental health history
• Substance use
• Pregnancy plans or contraception use

4. Understand Your Treatment Plan

Before ending your appointment, make sure you:

• Know why a specific medication was chosen
• Understand how to take it (dosing, timing, with/without food)
• Know what side effects to expect and which require immediate attention
• Have a clear follow-up schedule
• Know how to reach your provider between visits

5. Commit to the Process

Medication is just one tool in recovery from BED. For best results:

• Take medication as prescribed
• Attend follow-up appointments
• Consider adding therapy
• Track your progress (binge frequency, mood, side effects)
• Be patient—improvements often take weeks to months

Why Klarity Health for BED Treatment

At Klarity Health, we’ve built our telehealth platform specifically to address the barriers that keep people from accessing mental health and eating disorder care. Here’s what sets us apart:

Qualified, Licensed Providers: Our network includes psychiatrists and psychiatric nurse practitioners licensed in your state, with specific training in eating disorders and related conditions.

Comprehensive Evaluations: We don’t rush care. Our initial consultations are thorough, ensuring we understand your unique situation before recommending treatment.

Transparent Pricing: Whether you’re using insurance or paying out of pocket, you’ll know the cost upfront—no surprise bills.

Fast Appointments: Most patients can schedule an initial appointment within 3-5 days, with same-day options often available for urgent needs.

Flexible Payment: We accept most major insurance plans and offer affordable self-pay rates for those who prefer not to use insurance.

Ongoing Support: BED treatment is a journey, not a one-time prescription. We provide regular follow-up care and adjust your treatment as needed.

Integrated Approach: While we can prescribe medication, we also recognize when therapy, nutritional counseling, or other supports are needed—and we’ll help you access them.

Ready to take the first step toward recovery from Binge Eating Disorder? Visit Klarity Health to schedule a confidential evaluation with a licensed provider who understands eating disorders and can create a personalized treatment plan for you.

Frequently Asked Questions

Is it legal to get BED medication prescribed online?

Yes, it’s completely legal to receive prescriptions for non-controlled BED medications like topiramate or bupropion via telehealth, provided your prescriber is licensed in your state and conducts an appropriate evaluation.

Do I need an in-person visit first?

In most states, no in-person visit is required for non-controlled medications. A comprehensive telehealth evaluation is sufficient. A few states (Alabama, Georgia, New Hampshire) require periodic in-person visits for continuing care, but initial treatment can typically begin via telehealth.

Will my medication be covered by insurance?

Most insurance plans cover telehealth visits and the generic medications commonly used for BED. Coverage varies by plan, so check with your insurer or choose a platform that can verify benefits before your appointment.

How quickly can I get an appointment?

This varies by platform, but many telehealth services (including Klarity Health) can schedule appointments within a few days, with some offering same-day or next-day availability.

What if the medication doesn’t work?

Not everyone responds to the same medication. If your first choice isn’t effective or causes intolerable side effects, your provider can try a different medication or adjust your treatment plan. This is why regular follow-up is essential.

Can nurse practitioners prescribe these medications?

Yes, nurse practitioners can prescribe topiramate and bupropion in all states. In about two-thirds of states, they can do so independently; in others, they work under a collaborative agreement with a physician.

Are there any medications I shouldn’t take with BED drugs?

Both medications have potential interactions. Topiramate can interact with hormonal contraceptives, certain seizure medications, and carbonic anhydrase inhibitors. Bupropion shouldn’t be combined with MAO inhibitors and requires caution with other antidepressants. Always provide a complete medication list to your provider.

What if I have other mental health conditions?

Co-occurring conditions like depression, anxiety, or ADHD are common with BED. Your provider will assess all your symptoms and may adjust treatment accordingly. In some cases, one medication might help multiple conditions.

Is telehealth as effective as in-person treatment?

Research shows that telehealth mental health care can be just as effective as in-person treatment, with high patient satisfaction. The key is choosing a quality provider and engaging fully in your care.

What happens if I move to a different state?

Providers must be licensed in the state where you’re physically located during treatment. If you move, you’ll need to transfer care to a provider licensed in your new state. Many telehealth platforms operate in multiple states and can facilitate this transition.

Research Currency Statement

Verified as of: January 4, 2026

DEA Rules Status: COVID-19 telehealth prescribing flexibilities remain in effect through December 31, 2026 (fourth extension). No federal in-person requirement exists for non-controlled medications—these were never subject to the Ryan Haight Act restrictions on telemedicine. Controlled substance telehealth rules are temporary and extended through 2026 pending a permanent DEA rule.

States Verified: Researched 10+ key states (AL, CA, DE, FL, GA, NH, NY, TX, MI, WI, etc.) with latest information as of late 2025. State board sites and 2025 legislative updates were checked where available.

Sources Currency: 80%+ of sources are from 2025 (many late-2025) or updated to 2025. Older sources (2024) were used only when confirmed still accurate by newer references.

Flagged for Follow-Up: Alabama and South Carolina NP scope changes (legislation was discussed in 2025 but final status unclear—assume no full independence yet pending confirmation). Monitor DEA’s pending final rule on telehealth prescribing (expected by end of 2026). Verify any temporary state waivers for expiration/extension beyond 2025.

Citations

1. HHS Press Release (January 2026) – DEA telemedicine extension announcement through December 31, 2026. www.hhs.gov

2. Sheppard Mullin Health Law Blog (August 2025) – Federal and state updates to pandemic-era telehealth exceptions, clarifying that non-controlled medications were never restricted by Ryan Haight Act. www.sheppardhealthlaw.com

3. Center for Connected Health Policy (2025) – State-by-state telehealth policy database with updates on online prescribing requirements. www.cchpca.org

4. National Law Review (2025) – Analysis of state-specific telehealth regulations including New York’s 2025 final rule and Delaware’s SB 101. natlawreview.com

5. Health Jobs Nationwide Blog (2025) – State-by-state guide to expanding roles for NPs and PAs, including 2025 legislative updates for Michigan, Wisconsin, and other states. blog.healthjobsnationwide.com

Source:

• https://www.hhs.gov/press-room/dea-telemedicine-extension-2026.html#:~:text=patients%20to%20receive%20prescriptions%20for,while%20permanent%20rules%20are%20finalized
• https://www.sheppardhealthlaw.com/2025/08/articles/telehealth/telehealth-and-in-person-visits-tracking-federal-and-state-updates-to-pandemic-era-telehealth-exceptions/#:~:text=extended%20telemedicine%20prescribing%20waivers%20through,prescribing
• https://blog.healthjobsnationwide.com/state-by-state-guide-expanding-roles-for-pas-and-nps-updated-2025/#:~:text=Full%20practice%20authority%20legislation%20reached,12
• https://natlawreview.com/article/telehealth-and-person-visits-tracking-federal-and-state-updates-pandemic-era?amp=#:~:text=coordination%20with%20the%20U,prescribing
• https://telehealth.hhs.gov/providers/telehealth-policy/prescribing-controlled-substances-via-telehealth#:~:text=The%20Drug%20Enforcement%20Administration%20,through%20December%2031%2C%202025
• https://natlawreview.com/article/telehealth-and-person-visits-tracking-federal-and-state-updates-pandemic-era?amp=#:~:text=Prior%20to%20the%202024%20waiver,access%2C%20and%20diversion%20control%20measures
• https://www.cchpca.org/topic/online-prescribing/#:~:text=If%20a%20physician%20or%20practice,resolution%2C%20the%20physician%20shall%20either
• https://www.cchpca.org/topic/online-prescribing/#:~:text=Prescribing%2C%20dispensing%2C%20or%20furnishing%20dangerous,the%20appropriate%20standard%20of%20care
• https://www.cchpca.org/topic/online-prescribing/#:~:text=constitutes%20unprofessional%20conduct,the%20appropriate%20standard%20of%20care
• https://blog.healthjobsnationwide.com/state-by-state-guide-expanding-roles-for-pas-and-nps-updated-2025/#:~:text=California%20leads%20the%20most%20important,12