BACKGROUND: To improve understanding of influenza and rurality, we investigated differences in influenza testing and anti-viral treatment rates between micropolitan (muSAs) and metropolitan statistical areas (MSAs) using national medical claims data over multiple influenza seasons. METHODS: Using billing data from the Centers for Medicare and Medicaid Services for those aged 65 years and older, we estimated weekly rates of ordered rapid influenza diagnostic tests (RIDT) and antivirals (AV) among Medicare enrollees by core-based statistical areas (CBSAs) during 2010-2016. We used Negative Binomial generalized mixed models to estimate adjusted rate ratios (aRR) between MSAs and muSAs, adjusting for clustering by CBSA plus explanatory variables. We ran models for all weeks and only high influenza activity weeks. RESULTS: For all weeks, the unadjusted rate of RIDTs was 1.97 per 10,000 people in MSAs compared with 2.69 in muSAs (Rate ratio (RR) = 0.73, 95% Confidence Interval (CI): 0.73-0.74) and of AVs was 1.85 in MSAs compared with 1.40 in muSAs (RR = 1.32, CI: 1.31-1.32). From the multivariate model, aRR for RIDTs was 0.82 (0.73-0.94) and for AVs was 1.12 (1.04-1.22) in MSAs versus muSAs. For high influenza activity weeks, aRR for RIDTs was 0.82 (0.73-0.92) and for AVs was 1.15 (1.06-1.24). All models found influenza testing rates higher in muSAs and treatment rates higher in MSAs. CONCLUSIONS: Our study found lower testing and higher treatment in U.S. metropolitan versus micropolitan areas from 2010 to 2016 for those aged 65 years and older in our population. Identifying differences in influenza rates by rurality may improve public health response. Further research into the relationship of rurality and health disparities is needed.