Abstract: Insomnia is the most common and refractory complaint in Veterans with posttraumatic stress disorder (PTSD). This open-label pilot study of pimavanserin describes the experience of 6 adult Veterans with active PTSD and chronic insomnia. we recruited non-elderly, medically healthy Veterans with chronic insomnia disorder of at least moderate severity1and current PTSD, from clinics at MEDVAMC between December 19, 2019–March 20, 2020 (pandemic) and June 16, 2021–August 8, 2021. The characteristics of the 6 subjects were mean age 35.33 ± 6.35 years; 2 (33.33%) females; and mean education of 14 ± 1.79 years. Two (33.33%) were Black or African American, 3 were White (50%), and 1 was “Other” (16.67%). Two (33.33%) were Hispanic or Latino. Three (50%) were Army, 1 (16.7%) Navy, and 2 (33.3%) Marine Veterans. Time since active duty ranged from 3.6 to 15.6 years. All index traumas were deployment-related. Four (66.67%) had comorbid depressive disorders. One (16.7%) was taking a selective serotonin reuptake inhibitor. This preliminary experience suggests pimavanserin may be well-tolerated at bedtime in patients with severe insomnia associated with PTSD. Patients reported subjective improvement in their insomnia symptoms and requested to continue the medication after the study. Randomized controlled trials are needed to test the efficacy and safety of pimavanserin against placebo. Future studies should also examine the mechanisms by which pimavanserin may influence sleep quality.