Recent years have seen the increased utilization of ionic liquids (ILs) in the development and optimization of analytical methods. Their unique and eco-friendly properties and the ability to modify their structure allows them to be useful both at the sample preparation stage and at the separation stage of the analytes. The use of ILs for the analysis of pharmaceuticals seems particularly interesting because of their systematic delivery to the environment. Nowadays, they are commonly detected in many countries at very low concentration levels. However, due to their specific physiological activity, pharmaceuticals are responsible for bioaccumulation and toxic effects in aquatic and terrestrial ecosystems as well as possibly upsetting the body’s equilibrium, leading to the dangerous phenomenon of drug resistance. This review will provide a comprehensive summary of the use of ILs in various sample preparation procedures and separation methods for the determination of pharmaceuticals in environmental and biological matrices based on liquid-based chromatography (LC, SFC, TLC), gas chromatography (GC) and electromigration techniques (e.g., capillary electrophoresis (CE)). Moreover, the advantages and disadvantages of ILs, which can appear during extraction and separation, will be presented and attention will be given to the criteria to be followed during the selection of ILs for specific applications.