BACKGROUND To assess Pap smear utilization and compliance with screening recommendations, a study was conducted in a large midwestern HMO where cost is not a barrier to care. The purpose of the study was to examine rates of screening by age, identify the proportion of abnormal cytologic findings, and determine screening incidence for women with a diagnosis of cervical cancer. METHODS Computerized records on screening frequency over a 5-year interval were examined for 23,649 consecutively enrolled women ages 18-70. In addition, medical records were examined for patients with a cervical cancer diagnosis (n = 32). RESULTS Eighty-five percent of the women had at least one Pap smear within the 5-year duration. Nearly half (47%) obtained four to five tests, 30% obtained two or three tests, and 14% were screened only once during the 5 years. Percentages were similar across all age groups. Cytopathology reports indicated 95% of tests as normal, 4% as low-grade squamous intraepithelial lesions (SIL), <1% as high-grade squamous intraepithelial lesions, and 0.02% as suspected malignancy. Younger women were more likely to evidence SIL; older women were somewhat more likely to have carcinoma. For women with a cancer diagnosis, 63% had not been screened the previous year and 34% had no screening recorded for the prior 3 years. Twenty-two percent had no record of screening within the past 5 years compared with 8.5% of the total group. CONCLUSIONS In HMOs with prepayment, one would hypothesize that patients would obtain more regular preventive screening of all types, yet women at highest risk seemed less likely to obtain Pap smear screening. This group is not fully understood and probably represents the best opportunity to reduce morbidity, mortality, and expense from preventable cervical neoplasias.