Tyrosine kinase inhibitor (TKI) use is critical to the care of patients with chronic myeloid leukemia (CML). Quantitative BCR-ABL1 polymerase chain reaction (qPCR) testing every 3 months during the first year of TKI treatment is recommended to assure achievement of milestone response goals. Real-world evidence for the patterns of qPCR monitoring and TKI adherence in the older patient population is lacking. Using the Surveillance, Epidemiology, and End Results-Medicare database we identified 1192 patients aged >66 years (median age of 74 years) with newly-diagnosed CML followed for ≥13 months from TKI initiation. Nine hundred sixty five patients (81.0%) had at ≥1 test with 425 (35.7%) and 540 (45.3%) of patients tested during 1-2 and ≥3 quarters (optimal monitoring) of the first year from TKI initiation, respectively. In multivariable analysis, diagnosis in later years (compared with 2007-2010, 2011-2014 odds ratio [OR]=1.97, 95% confidence interval [CI]: 1.43-2.7, p<0.01; 2015-2017 OR=2.33, 95%CI: 1.66-3.27, p<0.01) and influenza vaccination before diagnosis, a proxy for healthcare access (OR=1.31, 95%CI: 1.01-1.70, p=0.04) were associated with optimal qPCR monitoring. Use of low-income subsidy and residing in census tracts with the lowest socioeconomic status were associated with less optimal monitoring. Patients with optimal monitoring were 60% more likely to be TKI adherent (OR=1.60, 95%CI: 1.11-2.31, p=0.01) and had improved 5-year survival (hazard ratio=0.66, 95%CI: 0.49-0.90, p<0.01). In this large "real-world" study of CML management patterns, many older patients had suboptimal molecular monitoring, which was associated with decreased TKI adherence and worse survival.