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Systolic/diastolic blood pressure of 130–139/80–89 mm Hg has been defined as stage I hypertension by the 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines. Drug treatment is recommended for stage I hypertensive patients aged ≥65 years without cardiovascular disease (CVD) in the 2017 ACC/AHA guidelines, but not in the 2018 Chinese guidelines. However, the cost-effectiveness of drug treatment among this subgroup of Chinese patients is unclear. This study developed a microsimulation model to compare costs and effectiveness of drug treatment and non-drug treatment for the subgroup of stage I hypertensive patients over a lifetime horizon from a government affordability perspective. Event rates of mortality and cardiovascular complications were estimated from three cohorts in Chinese population. Costs and health utilities were obtained from national statistics report and published literature. The model predicted that drug treatment generated quality-adjusted life year (QALY) of 13.52 and associated with expected costs of $6825 in comparison with 13.81 and $7328 produced by non-drug treatment over a lifetime horizon among stage I hypertensive patients aged ≥65 years without CVD. At a willingness-to-pay threshold of $8836/QALY (the gross domestic product per capita in 2017), drug treatment only had a 1.8% probability of being cost-effective compared with non-drug treatment after 10000 probabilistic simulations. Sensitivity analysis of treatment costs, benefits expected from treatment, health utilities, and discount rates did not change the results. Our results suggested that drug treatment was not cost-effective compared to non-drug treatment for stage I hypertensive patients aged ≥65 years without CVD in China.