HARRISBURG, Pa. (AP) — Pennsylvania’s independently elected fiscal watchdog is urging state lawmakers to rein in pharmacy benefit managers, saying the companies are allowed to operate in secrecy in ways that let them profit while driving up health care costs.

Auditor General Eugene DePasquale released an 18-page report Tuesday saying many other states have taken action to force more transparency on pharmacy benefit managers.

DePasquale’s report says Pennsylvania’s Medicaid program paid nearly $2.9 billion in 2017 to pharmacy benefit managers, an increase of 100 percent in four years.

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But DePasquale says there’s no way to verify how much went to profits because pharmacy benefit managers are subcontractors.

A trade association for the companies says clients have complete transparency and it says the report’s claims that pharmacy benefit managers pay community pharmacies unfairly is untrue.