Background Even in high performing health systems, some diabetes patients have poor blood pressure (BP) control due to poor medication adherence and lack of medication intensification. We examined whether the Adherence and Intensification of Medications (AIM) intervention, a pharmacist-led intervention combining elements found in efficacy studies to lower BP, improved BP among diabetes patients with persistent hypertension and poor refill adherence or insufficient medication intensification in two high-performing health systems. Methods and Results We conducted a prospective, multi-site cluster randomized pragmatic trial with randomization of 16 primary care teams at five medical centers (3 Veterans Affairs and 2 Kaiser Permanente) to the AIM intervention or usual care. The primary outcome was relative change in systolic BP (SBP), comparing 1,797 intervention to 2,303 control team patients, from 6-months preceding to 6-months following the 14-month intervention period. We examined shorter-term changes in SBP as a secondary outcome. The mean SBP decrease from 6 months prior to 6 months after the intervention period was approximately 9 mmHg in both arms. Mean SBPs of eligible intervention patients were 2.4 mmHg lower (95% CI: -3.4 to -1.5; P < 0.001) immediately after the intervention than those achieved by control patients. Conslusions The AIM program more rapidly lowered SBPs among intervention patients, but usual care patients achieved equally low SBP levels by 6 months after the intervention period. These findings show the importance of evaluating in different real-life clinical settings programs found in efficacy trials to be effective before urging their widespread adoption in all settings. Background Even in high performing health systems, some diabetes patients have poor blood pressure (BP) control due to poor medication adherence and lack of of intensification. We examined whether the Adherence and Intensification of Medications (AIM) intervention, a pharmacist-led intervention combining elements found in efficacy studies to lower BP, improved BP among diabetes patients with persistent hypertension and poor refill adherence or for drug intensification in two high-performing health systems. Methods and Results We conducted a prospective, multi-site cluster randomized pragmatic trial with randomization of 16 primary care teams at five medical centers (3 Veterans Affairs and 2 Kaiser Permanente) to the AIM intervention or usual care. The primary outcome was relative change in systolic BP (SBP), comparing 1,797 interventions to 2,303 control team patients, from 6 -months preceding to 6-months following the 14-month intervention period. We examined shor The mean SBP decrease from 6 months prior to 6 months after the intervention period was approximately 9 mmHg in both arms. Mean SBPs of eligible intervention patients were 2.4 mmHg lower (95% CI: - 3.4 to -1.5; P <0.001) immediately after the intervention than those achieved by controlling patients. Conslusions The AIM program more substantially lowered SBPs among intervention patients, but usual care patients achieved equally low SBP levels by 6 months after the intervention period. findings show the importance of evaluating in different real-life clinical settings programs found in efficacy trials to be effective before urging their widespread adoption in all settings.